diff --git "a/data/extracting_subclaim/subset_testset/extracted_subclaims_multiclinsum_test_en_1500_2000.json" "b/data/extracting_subclaim/subset_testset/extracted_subclaims_multiclinsum_test_en_1500_2000.json" new file mode 100644--- /dev/null +++ "b/data/extracting_subclaim/subset_testset/extracted_subclaims_multiclinsum_test_en_1500_2000.json" @@ -0,0 +1,33442 @@ +[ + { + "id": "multiclinsum_test_2601_en.txt", + "fulltext": "A 34-year-old Persian woman with a history of depression and Sjögren’s syndrome, currently being treated with fluoxetine, was brought to the emergency department (ED) by paramedics, presenting with nausea, hypotension, confusion, and drowsiness. Diagnosed with depression by a psychologist 6 months earlier, she had no previous history of overdose or self-harm. Approximately 4 hours before she arrived at the ED, she had taken about 40 hydroxychloroquine (HCQ) tablets (200 mg each) and 60 azathioprine tablets (50 mg each). Her baseline electrolyte levels 80 days before the incident were normal, indicating no prior hypocalcemia or hypokalemia.\nAdditionally, there were no previous instances of overdose, self-harm, or cardiac complications, further suggesting that the overdose was the cause of her current condition. She had vomited twice since the overdose. She had been under prednisolone, nonsteroidal anti-inflammatory drugs (NSAIDs, such as naproxen), and other painkillers for her pain management, but she stated that she did not overdose on these drugs. She had a family history of rheumatoid arthritis, but there was no family history of mental disorders.\nUpon arrival, her vital signs were as follows: a heart rate of 62 beats per minute, blood pressure of 70/50 mmHg, respiratory rate of 19 breaths per minute, and oxygen saturation of 97%. Her body temperature was 36.7 °C, and she weighed approximately 58 kg. Physical examination showed mydriasis with reactive pupils, a weak but normal-sounding heart, and weak pulses in both hands. She complained of lip and finger stiffness, with a positive Trousseau sign and a negative Chvostek’s sign observed. Initial electrocardiography (ECG) showed a mildly flattened T wave and prolonged QT interval (640 milliseconds). The echocardiography showed an ejection fraction (EF) of 55% and pulmonary arterial pressure (PAP) of 25 mmHg. No clonus, tremors, or signs of hyperreflexia were observed. Neurological examinations revealed weakness in her extremities and a Glasgow Coma Scale (GCS) score of 13, indicating she was confused but responsive to voices.\nLaboratory analyses of her blood and urine showed hypokalemia (potassium: 2.4 mmol/L), hypocalcemia (calcium: 7.5 mg/dL), hypoglycemia (blood glucose: 65 mg/dL), and a positive result for benzodiazepine, tramadol, buprenorphine, and morphine. She stated that she had not taken any of these substances and overdosed on azathioprine and HCQ only. Her blood gas analysis indicated metabolic acidosis with respiratory alkalosis. Complete blood count (CBC) revealed low levels of hemoglobin, red blood cells (RBC), hematocrit (HCT), total iron-binding capacity (TIBC), and iron levels. We also managed to find the patient’s last routine laboratory tests (80 days prior), in which all her findings were normal and indicated no hypocalcemia or hypokalemia before the incident. However, since there were no cardiac complications in the patient before the overdose, there was no previous ECG. She was transferred to the hospital’s poison control center owing to her initial findings . Our data, as depicted in Table , indicate that the patient’s baseline electrolyte levels, including calcium (9.6 mg/dL) and potassium (3.5 mmol/L), were within normal limits 80 days prior to the incident. She received intravenous ondansetron (8 mg), pantoprazole (40 mg), potassium chloride injection (30 mEq), and a mixture of 5% dextrose and 0.9% sodium chloride. Her blood pressure improved to an acceptable level overnight following the administration of 1000 cc each of 5% dextrose and 0.9% sodium chloride. An infusion of 100 mg of calcium gluconate, diluted in 5% dextrose, ameliorated her finger stiffness. Post potassium chloride injection, her QT interval shortened to 590 milliseconds, and the flattening of T waves improved.\nApproximately 24 hours after consuming HCQ and azathioprine, the patient reported nausea and headaches. She underwent a brain computed tomography (CT) scan and an ECG, which showed normal results . She received injections of ketorolac (30 mg), dexamethasone (8 mg), and ondansetron (2 mL) for her symptoms (nausea and headache). About 26 hours after admission, the patient chose to be discharged. She was prescribed calcium, iron, and folate supplements and was subsequently referred to therapy sessions with her psychologist.\nOne week later, during follow-up, the patient had fully recovered, and her blood tests showed no significant abnormalities. Consent for the publication of this case has been obtained from the patient. We confirm that all experiments were carried out following relevant guidelines and regulations. Informed consent for participation and publication was obtained from the patient. Postrecovery, the patient’s treatment regimen for Sjögren’s syndrome was thoroughly reviewed and adjusted to minimize future risks, highlighting the importance of individualized management in complex cases. The absence of immediate preoverdose health data presents a limitation in our case, possibly obscuring a complete understanding of the patient’s baseline health status before the overdose.", + "fulltext_subclaims": [ + "The patient is a 34-year-old Persian woman.", + "She has a history of depression.", + "She has a history of Sjögren’s syndrome.", + "She is currently being treated with fluoxetine.", + "She was brought to the emergency department by paramedics.", + "She presented with nausea.", + "She presented with hypotension.", + "She presented with confusion.", + "She presented with drowsiness.", + "She had no previous history of overdose.", + "She had no previous history of self-harm.", + "Approximately 4 hours before arriving at the ED, she had taken about 40 hydroxychloroquine tablets.", + "Each hydroxychloroquine tablet was 200 mg.", + "Approximately 4 hours before arriving at the ED, she had taken about 60 azathioprine tablets.", + "Each azathioprine tablet was 50 mg.", + "Her baseline electrolyte levels 80 days before the incident were normal.", + "There were no previous instances of cardiac complications.", + "She had vomited twice since the overdose.", + "She had been under prednisolone for pain management.", + "She had been under NSAIDs, such as naproxen, for pain management.", + "She stated that she did not overdose on prednisolone.", + "She stated that she did not overdose on NSAIDs.", + "She had a family history of rheumatoid arthritis.", + "There was no family history of mental disorders.", + "Upon arrival, her heart rate was 62 beats per minute.", + "Upon arrival, her blood pressure was 70/50 mmHg.", + "Upon arrival, her oxygen saturation was 97%.", + "Physical examination showed mydriasis with reactive pupils.", + "Physical examination showed a weak but normal-sounding heart.", + "Physical examination showed weak pulses in both hands.", + "She complained of lip and finger stiffness.", + "A positive Trousseau sign was observed.", + "A negative Chvostek’s sign was observed.", + "Initial ECG showed a mildly flattened T wave.", + "Initial ECG showed a prolonged QT interval of 640 milliseconds.", + "Echocardiography showed an ejection fraction of 55%.", + "Echocardiography showed pulmonary arterial pressure of 25 mmHg.", + "Neurological examinations revealed weakness in her extremities.", + "Her Glasgow Coma Scale score was 13.", + "Laboratory analyses showed hypokalemia (potassium: 2.4 mmol/L).", + "Laboratory analyses showed hypocalcemia (calcium: 7.5 mg/dL).", + "Laboratory analyses showed hypoglycemia (blood glucose: 65 mg/dL).", + "Blood gas analysis indicated metabolic acidosis with respiratory alkalosis.", + "Complete blood count revealed low levels of hemoglobin.", + "Complete blood count revealed low levels of red blood cells.", + "Complete blood count revealed low levels of hematocrit.", + "Complete blood count revealed low levels of total iron-binding capacity.", + "Complete blood count revealed low levels of iron.", + "The patient’s last routine laboratory tests 80 days prior showed normal findings.", + "The patient’s baseline calcium level 80 days prior was 9.6 mg/dL.", + "The patient’s baseline potassium level 80 days prior was 3.5 mmol/L.", + "She received intravenous ondansetron (8 mg).", + "She received intravenous pantoprazole (40 mg).", + "She received intravenous potassium chloride injection (30 mEq).", + "She received a mixture of 5% dextrose and 0.9% sodium chloride.", + "Her blood pressure improved to an acceptable level overnight.", + "She received 1000 cc each of 5% dextrose and 0.9% sodium chloride.", + "She received 100 mg of calcium gluconate diluted in 5% dextrose.", + "Post potassium chloride injection, her QT interval shortened to 590 milliseconds.", + "Approximately 24 hours after consuming HCQ and azathioprine, the patient reported nausea.", + "Approximately 24 hours after consuming HCQ and azathioprine, the patient reported headaches.", + "She underwent a brain CT scan.", + "The brain CT scan showed normal results.", + "She received injections of ketorolac (30 mg), dexamethasone (8 mg), and ondansetron (2 mL).", + "About 26 hours after admission, the patient chose to be discharged.", + "She was prescribed calcium, iron, and folate supplements.", + "She was referred to therapy sessions with her psychologist.", + "One week later, during follow-up, the patient had fully recovered.", + "Her blood tests showed no significant abnormalities.", + "Consent for the publication of this case has been obtained from the patient.", + "Postrecovery, the patient’s treatment regimen for Sjögren’s syndrome was reviewed.", + "The absence of immediate preoverdose health data presents a limitation." + ], + "summary": "A 34-year-old Persian woman with a history of Sjögren's syndrome presented to the emergency department 3.5-4 hours after an intentional overdose of hydroxychloroquine and azathioprine and severe hypotension and loss of consciousness. Although the patient was regularly taking other medications, such as fluoxetine, naproxen, and prednisolone, she explicitly clarified that these were not the substances involved in her overdose. Early investigations showed hypokalemia (2.4 mEq/L), hypocalcemia (7.5 mg/dL), and hypoglycemia (65 mg/dL). She was also diagnosed with metabolic acidosis and respiratory alkalosis. The electrocardiogram showed changes in favor of hypokalemia; other lab tests were run on the patient. Supportive treatments were applied, including rapid intravenous fluid dextrose 5%, normal saline, potassium chloride 30 mEq, and calcium gluconate 100 mg. The patient was managed and monitored overnight in the emergency room and recovered without residual side effects.", + "summary_subclaims": [ + "The patient is a 34-year-old Persian woman.", + "She has a history of Sjögren's syndrome.", + "She presented to the emergency department 3.5-4 hours after an intentional overdose.", + "The overdose involved hydroxychloroquine and azathioprine.", + "She had severe hypotension and loss of consciousness.", + "She was regularly taking fluoxetine, naproxen, and prednisolone.", + "She explicitly clarified that fluoxetine, naproxen, and prednisolone were not the substances involved in her overdose.", + "Early investigations showed hypokalemia (2.4 mEq/L).", + "Early investigations showed hypocalcemia (7.5 mg/dL).", + "Early investigations showed hypoglycemia (65 mg/dL).", + "She was diagnosed with metabolic acidosis.", + "She was diagnosed with respiratory alkalosis.", + "The electrocardiogram showed changes in favor of hypokalemia.", + "Other lab tests were run on the patient.", + "Supportive treatments included rapid intravenous fluid dextrose 5%.", + "Supportive treatments included normal saline.", + "Supportive treatments included potassium chloride 30 mEq.", + "Supportive treatments included calcium gluconate 100 mg.", + "The patient was managed and monitored overnight in the emergency room.", + "The patient recovered without residual side effects." + ] + }, + { + "id": "multiclinsum_test_2510_en.txt", + "fulltext": "A 15-year-old male (height, 159 cm; weight, 43 kg) presented to the emergency department with sudden severe central chest pain radiating to the left shoulder. His blood pressure was 83/56 mmHg, pulse 84 beats/minute, and body temperature 36.1°C. His cardiovascular physical examination was unremarkable, and no evidence of connective tissue disorder and vasculitis was apparent.\nHe and his family history were unremarkable for cardiovascular disease, vasculitis, and connective tissue diseases including Marfan syndrome. He had undergone video-assisted thoracic surgery (VATS) for bilateral spontaneous pneumothorax 3 months before and for left pneumothorax 2 months before at the former hospital.\nThe initial electrocardiogram (ECG) showed sinus tachycardia with ST-segment elevation in leads I, II, III, aVF, and V2 to V6 . Laboratory investigations showed an elevated white blood cell count at 25.0 × 109/L (normal value: 3.3–8.6 × 109/L) and a normal level of C-reactive protein at 0.1 mg/L (normal value: 0.0–1.4 mg/L). Creatine kinase (CK), CKMB, and troponin I were within normal limits at 75 U/L (normal value: 59–248 U/L), 17 U/L (normal value: 0–20 U/L), 0.01 ng/mL (normal value: 0.00–0.09 ng/mL), respectively. Chest X-ray revealed a slightly enlarged cardiac silhouette . Contrast-enhanced computed tomography (CT) revealed significant pericardial effusion of which Hounsfield unit was approximately 50 HU, suggesting that it might be high protein fluid or bloody. There was no evidence of pulmonary embolism or aortic dissection. Transthoracic echocardiogram revealed a large pericardial effusion with normal left ventricular size and function with an ejection fraction of 68% (Videos 1 and 2).\nBased on the clinical history and the ECG findings, our working diagnosis was pericarditis of unknown origin. The differential diagnosis included infectious pericarditis (viral or tubercular) and non-infectious pericarditis (autoimmune or autoinflammatory diseases, pericardial injury syndromes, and malignancies).\nWe managed him with a conservative strategy, including treatment with ibuprofen. On the third day after admission, echocardiogram showed decreasing pericardial effusion and ECG showed improvement of ST elevation. Laboratory investigations for bacteria, Mycobacterium tuberculosis, and collagen vascular diseases were negative. His course was carefully monitored because he was young and had near-fatal event. On the morning of the day 12, we confirmed that the pericardial effusion had decreased. On hospital day 13, he experienced sudden severe chest pain after vomiting, became diaphoretic, and developed cardiogenic shock. An echocardiogram revealed the pericardial effusion to have increased to > 30 mm with tamponade physiology. He underwent emergent pericardiocentesis and drainage of 300 mL of blood (haemoglobin of the fluid was 12.8 g/dL). Bacterial cultures and cytology were negative. A full body 18F-fluorodeoxyglucose (FDG) positive emission tomography scan for detecting malignancies revealed no significant FDG uptake. Coronary angiography showed a 2 mm saccular-shaped pseudoaneurysm in the posterolateral (PL) branch of right coronary artery (RCA) (Video 3). We recognized that rupture of the coronary pseudoaneurysm caused the acute haemopericardium. Based on his past medical history, we speculated that the coronary pseudoaneurysm was caused by trauma associated with prior procedures for pneumothoraces.\nWe treated the coronary pseudoaneurysm by percutaneous management with coil embolization. The procedure was performed via the right femoral artery approach. Using Runthrough NS floppy (Terumo, Tokyo, Japan) guidewire with Heartrail II JR3.5 catheter (Terumo, Tokyo, Japan), the guidewire and Excelsior SL-10 (Stryker Neurovascular, Fremont, CA, USA) microcatheter were successfully inserted to the PL branch of RCA (, ). One detachable coil; 2 mm × 8 mm Trufill DCS Orbit® (Codman Neurovascular, Raynham, MA, USA) was delivered through a microcatheter (, ). A final angiogram showed obliteration of blood flow to the pseudoaneurysm (, ).\nThe patient experienced chest pain for 1 day after the procedure, although post-procedural echocardiogram did not show any abnormality (, and ). He had no symptoms on the second post-procedural day. Post-procedural electrocrdiogram showed inverted T waves in leads III, aVF . He was discharged 12 days after the procedure.", + "fulltext_subclaims": [ + "The patient is a 15-year-old male.", + "The patient's height is 159 cm.", + "The patient's weight is 43 kg.", + "The patient presented with sudden severe central chest pain radiating to the left shoulder.", + "The patient's blood pressure was 83/56 mmHg.", + "The patient's pulse was 84 beats/minute.", + "The patient's body temperature was 36.1°C.", + "The cardiovascular physical examination was unremarkable.", + "There was no evidence of connective tissue disorder.", + "There was no evidence of vasculitis.", + "The patient and his family history were unremarkable for cardiovascular disease.", + "The patient and his family history were unremarkable for vasculitis.", + "The patient and his family history were unremarkable for connective tissue diseases including Marfan syndrome.", + "The patient had undergone video-assisted thoracic surgery (VATS) for bilateral spontaneous pneumothorax 3 months before.", + "The patient had undergone VATS for left pneumothorax 2 months before.", + "The initial electrocardiogram showed sinus tachycardia.", + "The initial ECG showed ST-segment elevation in leads I, II, III, aVF, and V2 to V6.", + "The white blood cell count was 25.0 × 109/L.", + "The C-reactive protein level was 0.1 mg/L.", + "Creatine kinase was within normal limits at 75 U/L.", + "CKMB was within normal limits at 17 U/L.", + "Troponin I was within normal limits at 0.01 ng/mL.", + "Chest X-ray revealed a slightly enlarged cardiac silhouette.", + "Contrast-enhanced CT revealed significant pericardial effusion.", + "The pericardial effusion had a Hounsfield unit of approximately 50 HU.", + "There was no evidence of pulmonary embolism.", + "There was no evidence of aortic dissection.", + "Transthoracic echocardiogram revealed a large pericardial effusion.", + "The left ventricular ejection fraction was 68%.", + "The working diagnosis was pericarditis of unknown origin.", + "The differential diagnosis included infectious pericarditis.", + "The differential diagnosis included non-infectious pericarditis.", + "The patient was managed with a conservative strategy.", + "The patient was treated with ibuprofen.", + "On the third day after admission, echocardiogram showed decreasing pericardial effusion.", + "On the third day after admission, ECG showed improvement of ST elevation.", + "Laboratory investigations for bacteria were negative.", + "Laboratory investigations for Mycobacterium tuberculosis were negative.", + "Laboratory investigations for collagen vascular diseases were negative.", + "On hospital day 13, the patient experienced sudden severe chest pain after vomiting.", + "On hospital day 13, the patient became diaphoretic.", + "On hospital day 13, the patient developed cardiogenic shock.", + "An echocardiogram revealed the pericardial effusion to have increased to > 30 mm.", + "An echocardiogram revealed tamponade physiology.", + "The patient underwent emergent pericardiocentesis.", + "The patient had 300 mL of blood drained.", + "The haemoglobin of the fluid was 12.8 g/dL.", + "Bacterial cultures were negative.", + "Cytology was negative.", + "A full body 18F-fluorodeoxyglucose (FDG) PET scan revealed no significant FDG uptake.", + "Coronary angiography showed a 2 mm saccular-shaped pseudoaneurysm in the posterolateral branch of the right coronary artery.", + "The rupture of the coronary pseudoaneurysm caused the acute haemopericardium.", + "The coronary pseudoaneurysm was caused by trauma associated with prior procedures for pneumothoraces.", + "The patient was treated with percutaneous management with coil embolization.", + "The procedure was performed via the right femoral artery approach.", + "One detachable coil was delivered through a microcatheter.", + "The coil was 2 mm × 8 mm Trufill DCS Orbit®.", + "A final angiogram showed obliteration of blood flow to the pseudoaneurysm.", + "The patient experienced chest pain for 1 day after the procedure.", + "Post-procedural echocardiogram did not show any abnormality.", + "Post-procedural electrocardiogram showed inverted T waves in leads III, aVF.", + "The patient was discharged 12 days after the procedure." + ], + "summary": "A 15-year-old male patient with a history of spontaneous pneumothoraces treated twice with video-assisted thoracoscopic thoracic surgery presented with pericarditis and increasing haemopericardium. During the hospitalization, he had developed cardiogenic shock and he underwent emergent pericardiocentesis. Coronary angiography revealed a small right coronary artery pseudoaneurysm. We successfully coil embolized the pseudoaneurysm.", + "summary_subclaims": [ + "The patient is a 15-year-old male.", + "The patient has a history of spontaneous pneumothoraces.", + "The patient was treated twice with video-assisted thoracoscopic thoracic surgery.", + "The patient presented with pericarditis.", + "The patient had increasing haemopericardium.", + "The patient had developed cardiogenic shock.", + "The patient underwent emergent pericardiocentesis.", + "Coronary angiography revealed a small right coronary artery pseudoaneurysm.", + "We successfully coil embolized the pseudoaneurysm." + ] + }, + { + "id": "multiclinsum_test_411_en.txt", + "fulltext": "A 56-year-old woman presented to the emergency department with headache and right hemiparesis. Blood screening did not indicate any signs of infection, but she had the history of ovarian tumor resection. A computed tomography (CT) scan revealed a hyperdense mass in the right frontal lobe . MRI showed a nodular mass, with maximum diameter of 11 mm that was hypointense on FLAIR with perifocal edema. After gadolinium administration, the mass showed a ring enhancement [-]. Magnetic resonance angiography showed regular blood flow in the intracranial arteries. Because of the ring enhancement and surrounding FLAIR high signal, there was a significant probability of a metastatic brain tumor. We performed right temporal craniotomy with neuronavigation (BrainLab AG, Germany). Dissection was performed through the inferior frontal gyrus down to the level of the lesion. The preparation showed a hard spherical lesion with vasa vasorum at the lesion wall. Further, the lesion wall was grayish black and was found to be a thrombosed aneurysm originating from the distal temporal branch of the right MCA (M3 segment). Distal vessels exiting the aneurysm were seen, which were draped under the surface of the aneurysm, these were freed from the aneurysm dome . It was observed that they were not supplying the distal territory of MCA. At this time, a 4 mm permanent clip was placed across the distal vessel of the aneurysm. The proximal portion of the aneurysm and the parent vessel were identified and coagulated. We also clipped the proximal vessel . The aneurysm was fusiform in appearance. The aneurysm was then resected using micro scissors, cutting the proximal portion away from the permanent aneurysm clips, and then removing the distal portion of the aneurysm . The intraoperativeindocyanine green angiography demonstrated absence of blood flow in the aneurysm . It was observed that they were not supplying the distal territory of MCA. Histopathologicalfindings confirmed the thrombosed aneurysm and reveals remarkable angiogenesis of vasa vasorum .\nPostoperatively, the patient was stable and had no neurological deficits. A collateral circulation from the MCA and posterior circulation was detected. After 1-month of follow-up, the patient recovered from the surgery and could walk without assistance.", + "fulltext_subclaims": [ + "The patient was a 56-year-old woman.", + "She presented to the emergency department with headache and right hemiparesis.", + "Blood screening did not indicate any signs of infection.", + "She had a history of ovarian tumor resection.", + "A CT scan revealed a hyperdense mass in the right frontal lobe.", + "MRI showed a nodular mass with a maximum diameter of 11 mm.", + "The mass was hypointense on FLAIR with perifocal edema.", + "After gadolinium administration, the mass showed a ring enhancement.", + "Magnetic resonance angiography showed regular blood flow in the intracranial arteries.", + "There was a significant probability of a metastatic brain tumor.", + "A right temporal craniotomy with neuronavigation was performed.", + "Dissection was performed through the inferior frontal gyrus down to the level of the lesion.", + "The preparation showed a hard spherical lesion with vasa vasorum at the lesion wall.", + "The lesion wall was grayish black.", + "The lesion was found to be a thrombosed aneurysm originating from the distal temporal branch of the right MCA (M3 segment).", + "Distal vessels exiting the aneurysm were seen, which were draped under the surface of the aneurysm.", + "These vessels were freed from the aneurysm dome.", + "It was observed that they were not supplying the distal territory of MCA.", + "A 4 mm permanent clip was placed across the distal vessel of the aneurysm.", + "The proximal portion of the aneurysm and the parent vessel were identified and coagulated.", + "The proximal vessel was clipped.", + "The aneurysm was fusiform in appearance.", + "The aneurysm was resected using micro scissors.", + "The intraoperative indocyanine green angiography demonstrated absence of blood flow in the aneurysm.", + "Histopathological findings confirmed the thrombosed aneurysm.", + "Histopathological findings revealed remarkable angiogenesis of vasa vasorum.", + "Postoperatively, the patient was stable and had no neurological deficits.", + "A collateral circulation from the MCA and posterior circulation was detected.", + "After 1-month of follow-up, the patient recovered from the surgery.", + "The patient could walk without assistance." + ], + "summary": "Here, we report an extremely rare case of a right frontal mass mimicking a brain tumor, in which the surgery unveiled a CTIA of the right middle cerebral artery (MCA). A 56-year-old woman presented with right hemiparesis and mild headache. Magnetic resonance imaging (MRI) revealed a right frontal mass with peripheral edema. The lesion enhanced on initial and follow-up MRI of the brain. Subsequent vascular studies and metastatic workup were negative. A temporal craniotomy with neuronavigation (Brain Lab AG, Germany) was performed and an intraoperative diagnosis of a thrombosed aneurysm along the branch of the MCA was established. The aneurysm was successfully trapped and resected. The patient did not exhibit any postoperative neurological deficits.", + "summary_subclaims": [ + "This is an extremely rare case of a right frontal mass mimicking a brain tumor.", + "The surgery revealed a CTIA of the right middle cerebral artery.", + "The patient was a 56-year-old woman.", + "She presented with right hemiparesis and mild headache.", + "MRI revealed a right frontal mass with peripheral edema.", + "The lesion enhanced on initial and follow-up MRI of the brain.", + "Subsequent vascular studies and metastatic workup were negative.", + "A temporal craniotomy with neuronavigation (Brain Lab AG, Germany) was performed.", + "An intraoperative diagnosis of a thrombosed aneurysm along the branch of the MCA was established.", + "The aneurysm was successfully trapped and resected.", + "The patient did not exhibit any postoperative neurological deficits." + ] + }, + { + "id": "multiclinsum_test_847_en.txt", + "fulltext": "A 69-year-old Greek female patient presented at our emergency department (ED) with a two-hour history of abdominal pain and vomiting. Her medical history was unremarkable except for previous cholecystectomy and appendectomy. The patient did not take any medications, and she was not a smoker or an alcohol consumer.\nShe looked ill with a blood pressure of 130/85 mm/Hg, a pulse rate of 90 beats/min, respirations of 25 breaths/min and a temperature of 38.5°C. A thorough physical examination revealed diffuse abdominal tenderness on deep palpation without any other signs of peritonitis. The laboratory examination was unremarkable except for polymorphonuclear leucocytosis (white blood cell [WBC] count, 15 × 103/μL; neutrophils, 86%) and an elevated C-reactive protein (14 mg/dL; reference range, 0-5). An upright chest radiograph demonstrated free subdiaphragmatic air bilaterally , which seemed to be increasing during air insufflation in the stomach via a nasogastric tube . Abdominal ultrasound examination was unremarkable.\nAn emergency laparotomy was performed for a suspected perforation in the upper GI tract. A few adhesions caused by previous cholecystectomy and appendicectomy were observed without any signs of peritoneal irritation or peritoneal fluid. The stomach and duodenum were fully mobilized, and the lesser sac was explored, but no evidence of perforation was found in the distal esophagus, stomach or duodenum. The small bowel and colon were also examined, but no leakage was observed. Subsequently, dilution of methylene blue in normal saline was instilled into the stomach through the nasogastric tube, but no obvious leakage was noted. Afterward, the abdominal cavity was filled with 2000 cc of normal saline, and air was again infused through the nasogastric tube into the stomach, but no air leakage from the upper GI tract was noted. Finally, because no cause of the pneumoperitoneum had been found, the operation was completed by placing a double-lumen drain.\nThe postoperative course was uneventful, and the patient showed a significant and prompt recovery. The subdiaphragmatic air disappeared six days postoperatively . The patient was discharged home on the seventh postoperative day. One month later, esophagogastroduodenoscopy, colonoscopy and abdominal computed tomography (CT) were performed, but no pathology was detected.", + "fulltext_subclaims": [ + "The patient was a 69-year-old Greek female.", + "She presented at the emergency department with a two-hour history of abdominal pain and vomiting.", + "Her medical history was unremarkable except for previous cholecystectomy and appendectomy.", + "She did not take any medications.", + "She was not a smoker.", + "She was not an alcohol consumer.", + "She looked ill.", + "Her blood pressure was 130/85 mm/Hg.", + "Her pulse rate was 90 beats/min.", + "Her respirations were 25 breaths/min.", + "Her temperature was 38.5°C.", + "Physical examination revealed diffuse abdominal tenderness on deep palpation.", + "There were no other signs of peritonitis.", + "The laboratory examination was unremarkable except for polymorphonuclear leucocytosis.", + "The white blood cell count was 15 × 103/μL.", + "The neutrophil count was 86%.", + "The C-reactive protein was 14 mg/dL.", + "An upright chest radiograph demonstrated free subdiaphragmatic air bilaterally.", + "The subdiaphragmatic air seemed to be increasing during air insufflation in the stomach via a nasogastric tube.", + "An emergency laparotomy was performed for a suspected perforation in the upper GI tract.", + "A few adhesions caused by previous cholecystectomy and appendicectomy were observed.", + "No signs of peritoneal irritation were observed.", + "No peritoneal fluid was observed.", + "The stomach and duodenum were fully mobilized.", + "The lesser sac was explored.", + "No evidence of perforation was found in the distal esophagus, stomach, or duodenum.", + "The small bowel and colon were examined.", + "No leakage was observed.", + "Dilution of methylene blue in normal saline was instilled into the stomach through the nasogastric tube.", + "No obvious leakage was noted.", + "The abdominal cavity was filled with 2000 cc of normal saline.", + "Air was again infused through the nasogastric tube into the stomach.", + "No air leakage from the upper GI tract was noted.", + "The operation was completed by placing a double-lumen drain.", + "The postoperative course was uneventful.", + "The patient showed a significant and prompt recovery.", + "The subdiaphragmatic air disappeared six days postoperatively.", + "The patient was discharged home on the seventh postoperative day.", + "One month later, esophagogastroduodenoscopy, colonoscopy, and abdominal computed tomography were performed.", + "No pathology was detected." + ], + "summary": "We present the case of an idiopathic spontaneous pneumoperitoneum. A 69-year-old Greek woman presented with acute abdominal pain, fever and vomiting. Diffuse abdominal tenderness on deep palpation without any other signs of peritonitis was found during physical examination, and laboratory investigations revealed leukocytosis and intraperitoneal air below the diaphragm bilaterally. Her medical history was unremarkable except for previous cholecystectomy and appendectomy. The patient did not take any medication, and she was not a smoker or an alcohol consumer. Emergency laparotomy was performed, but no identifiable cause was found. A remarkable improvement was noticed, and the patient was discharged on the seventh postoperative day, although the cause of pneumoperitoneum remained obscure.", + "summary_subclaims": [ + "The patient is a 69-year-old Greek woman.", + "The patient presented with acute abdominal pain.", + "The patient had fever.", + "The patient had vomiting.", + "Diffuse abdominal tenderness on deep palpation was found.", + "No other signs of peritonitis were found.", + "Laboratory investigations revealed leukocytosis.", + "Intraperitoneal air below the diaphragm bilaterally was found.", + "The patient's medical history was unremarkable except for previous cholecystectomy and appendectomy.", + "The patient did not take any medication.", + "The patient was not a smoker.", + "The patient was not an alcohol consumer.", + "Emergency laparotomy was performed.", + "No identifiable cause was found.", + "A remarkable improvement was noticed.", + "The patient was discharged on the seventh postoperative day.", + "The cause of pneumoperitoneum remained obscure." + ] + }, + { + "id": "multiclinsum_test_1097_en.txt", + "fulltext": "A girl, now 20 years old, presented to our hospital for the first time at the age of 7 years and 8 months, with multiple-joint swelling and limited motion for more than 5 years and recurrent fever for 18 months. Her long-term history of arthritis could be traced back to when she started to suffer from symmetrical polyarthritis at the age of 2 years, and her arthritis was in both knees, both wrists, the metacarpophalangeal joints, the proximal and distal phalangeal joints. She presented to the pediatric doctors in the local hospital by her parents and was diagnosed with juvenile idiopathic arthritis (JIA). The doctor treated her mostly with nonsteroidal anti-inflammatory drugs (NSAIDs) and methotrexate (MTX). During the following 5 years, her symptoms were not well controlled. At the age of 6 years, she had repeated and unexplained fevers. Anti-infection and symptomatic treatment were given but were ineffective. She was taken to her local pediatrician many times and received steroid treatment for several months. When she was 7 years of age, she complained of attacks of redness in both eyes but denied any history of vision loss. She was diagnosed with anterior uveitis of both eyes and her ocular symptoms disappeared after receiving ophthalmic treatment (tobramycin dexamethasone eye drops). Regarding her complete past medical history, in addition to the above manifestations, she had a squamous rash once at 10 months of age, which was ignored by her parents at that time.\nIn August 2009, when she was 8 years and 9 months old, the girl was referred to our hospital for the first time regarding recurrent arthritis in the absence of ocular complaints, rash and other symptoms. There was no other contributory past medical or history or family history. Physical examination revealed swan neck deformities of all fingers , limited joint mobility, swelling of the wrists, elbows, and knees, and a positive right 4-word test. No other remarkable findings were observed on physical examination. Blood tests showed a significant increase in the C-reactive protein (CRP) level and erythrocyte sedimentation rate (ESR). Her rheumatoid factor and human leukocyte antigen B27 (HLA-B27) were negative. No positive findings were found on her ophthalmic examination. MRI and other imaging examinations supported the manifestations of arthritis. With a diagnosis of JIA (polyarticular, RF negative), treatment was initiated and consisted of Etanercept, recombinant human tumor necrosis factor-Fc (rhTNFR:Fc), 0.8 mg/kg per week combined with MTX and NSAIDs. She showed improvement in her joint swelling and fever, but these symptoms still had recurred. In the following 10 years, the patient was followed up irregularly, and she had stopped etanercept on her own. Between 2015 and 2019, she was intermittently treated with prednisolone at doses ranging from 2.5 mg to 10 mg per day. Regrettably, the girl had vision loss in both eyes in 2018. An ocular examination showed obsolete iridocyclitis in both eyes and left eye cataracts. She underwent left eye cataract surgery in May 2018 in the Ophthalmology & Otorhinolaryngology Hospital, and her visual acuity recovered after the operation. In October 2019, she developed unexplained hypertension, which was found on a routine physical examination at school. She was referred to the local hospital and given nifedipine, but her blood pressure was not controlled.\nOn October 24, 2019, the girl was transferred to our hospital. Physical examination revealed that her blood pressure (BP) was 140/70 mmHg in the left upper limb, 139/79 mmHg in the right upper limb, 167/76 mmHg in the left lower limb, and 165/67 mmHg in the right lower limb. Before this, her blood pressure was increased once in a visit in 2017 in the only few outpatient visits, and was normal at other times. Moreover, she had painless fixed flexion deformities of multiple joints on physical examination. Additionally, ophthalmologic checks showed bilateral band-shaped degeneration of the cornea, with a corrected visual acuity of 0.4 in the right eye (OD) and 0.3 in the left eye (OS). She was diagnosed with bilateral panuveitis by an ophthalmologist. Various laboratory tests were ordered, and the results were as follows: her 24-h urinary protein excretion was 0.19 g and her serum creatinine was 102 μmol/L. We collected data on the serum creatinine (Scr) and eGFR of the patient during the past 10 years . According to the results, her Scr began to increase (ranging from 75 to 92 μmol/L) in approximately 2017 and finally increased to 102 μmol/L in October 2019. Her renin–angiotensin–aldosterone, CRP, ESR and thyroid hormone were within the normal ranges. Her autoantibodies were negative. Ambulatory blood pressure monitoring (ABPM) showed that the 24-h average BP was 143/83 mmHg (> 130/80 mmHg), the daytime average BP was 144/86 mmHg (> 135/85 mmHg) the and nighttime mean BP was 140/76 mmHg (> 120/70 mmHg).\nB ultrasound demonstrated that the right kidney (8.85*3*3.42 cm) was smaller than the left kidney (10.2*3.86*4.05 cm). The difference in length between the two kidneys was 1.35 cm. We searched and summarized all the renal B ultrasound data of the patient in the past 10 years compared with kidney length normative values in children . The sizes of the kidneys did not increase with age, the right kidney gradually decreased in size, and the size difference of both kidneys gradually increased. 99mTc-DTPA renography demonstrated that the right kidney was smaller than the left kidney with poor renal perfusion and impaired renal function . The GFR [ml·min-1·(1.73 m2)-1] of the kidneys was 74.4 (right kidney 30.8, left kidney 43.6). A significant difference was observed in the two splits of renal function: the renal function was 41.4% in the right kidney and was 58.6% in the left kidney. Computed tomography angiography (CTA) of the renal artery illustrated that the branches of the renal artery in the right hilum had mild stenosis , and the right kidney was smaller than the left kidney . No significant abnormalities were observed in the thoracic aorta, abdominal aorta, or cerebrovascular system. No remarkable findings were revealed on echocardiography and during an electrocardiogram. To further clarify the situation of the patients’s renal vessels, we also suggested performing digital angiography. However, her parents refused this invasive examination. The patient was diagnosed with right renal vasculitis through CTA of the renal artery (mild stenosis in the branch of the renal artery of the right renal hilus) and 99mTc-DTPA renography (difference in bilateral renal function and GFR) based on her two unequally sized kidneys (the gradually shrinking right kidney and the normal left kidney).\nIn view of the clinical manifestations mentioned above, including recurrent polyarthritis, fever, bilateral panuveitis and kidney involvement in medium-vessel vasculitis, it was obvious that this girl might in fact not have JIA. The diagnosis was likely an autoinflammatory disease. Thus, we performed whole genome sequencing (WGS) for the patient and her family. The results revealed that she had a de-novo heterozygous mutation in the NOD2 gene (c.1538 T > C, p.M513T) , with her parents presenting with the wild type. The M513T (1538 T/C) mutation was a heterozygous mutation and has been reported previously. According to the presentation and genetic test results, she was finally diagnosed with Blau syndrome and renovascular hypertension.\nConsidering her ocular lesions and unsatisfactory therapeutic effect, we suggested treating her with an anti-TNF-α monoclonal antibody (adalimumab) based on the previous studies . However, the patient refused the treatment because of financial reasons. Finally, she temporarily accepted a low dose of oral prednisolone, MTX, metoprolol and plendil. Her BP was gradually decreased and was controlled at approximately 130/80 mmHg. The OD and OS corrected vision were gradually restored to 0.6 after approximately 3 months. Her serum creatinine level slightly decreased and remained between 80–90 μmol/L after nearly 3 months of follow-up. In February 2020, she was referred to an adult hospital after reaching the age of 18. In the latest telephone consultation with the patient in December 2022, she stated that she was receiving prednisolone (15 mg/day) and tofacitinib (5 mg bid), and MTX had been discontinued because of abnormal transaminase. There were no new symptoms in the joints or eyes. There were also no rashes. Hematology examinations indicated that the patient’s ESR (25 mm/h) and serum creatinine (138 μmol/L) had increased. Her blood pressure was maintained at approximately 140/90 mmHg without any antihypertensive therapy.", + "fulltext_subclaims": [ + "The girl, now 20 years old, presented to our hospital for the first time at the age of 7 years and 8 months.", + "She had multiple-joint swelling and limited motion for more than 5 years.", + "She had recurrent fever for 18 months.", + "Her long-term history of arthritis could be traced back to when she started to suffer from symmetrical polyarthritis at the age of 2 years.", + "Her arthritis was in both knees, both wrists, the metacarpophalangeal joints, the proximal and distal phalangeal joints.", + "She was diagnosed with juvenile idiopathic arthritis (JIA).", + "The doctor treated her mostly with nonsteroidal anti-inflammatory drugs (NSAIDs) and methotrexate (MTX).", + "During the following 5 years, her symptoms were not well controlled.", + "At the age of 6 years, she had repeated and unexplained fevers.", + "Anti-infection and symptomatic treatment were given but were ineffective.", + "She was taken to her local pediatrician many times and received steroid treatment for several months.", + "When she was 7 years of age, she complained of attacks of redness in both eyes.", + "She was diagnosed with anterior uveitis of both eyes.", + "Her ocular symptoms disappeared after receiving ophthalmic treatment (tobramycin dexamethasone eye drops).", + "She had a squamous rash once at 10 months of age.", + "In August 2009, when she was 8 years and 9 months old, the girl was referred to our hospital for the first time regarding recurrent arthritis.", + "There was no other contributory past medical or family history.", + "Physical examination revealed swan neck deformities of all fingers.", + "Physical examination revealed limited joint mobility.", + "Physical examination revealed swelling of the wrists, elbows, and knees.", + "Physical examination revealed a positive right 4-word test.", + "Blood tests showed a significant increase in the C-reactive protein (CRP) level.", + "Blood tests showed a significant increase in the erythrocyte sedimentation rate (ESR).", + "Her rheumatoid factor and human leukocyte antigen B27 (HLA-B27) were negative.", + "No positive findings were found on her ophthalmic examination.", + "MRI and other imaging examinations supported the manifestations of arthritis.", + "With a diagnosis of JIA (polyarticular, RF negative), treatment was initiated.", + "Treatment consisted of Etanercept, recombinant human tumor necrosis factor-Fc (rhTNFR:Fc), 0.8 mg/kg per week combined with MTX and NSAIDs.", + "She showed improvement in her joint swelling and fever.", + "These symptoms still had recurred.", + "In the following 10 years, the patient was followed up irregularly.", + "She had stopped etanercept on her own.", + "Between 2015 and 2019, she was intermittently treated with prednisolone at doses ranging from 2.5 mg to 10 mg per day.", + "The girl had vision loss in both eyes in 2018.", + "An ocular examination showed obsolete iridocyclitis in both eyes and left eye cataracts.", + "She underwent left eye cataract surgery in May 2018.", + "Her visual acuity recovered after the operation.", + "In October 2019, she developed unexplained hypertension.", + "She was referred to the local hospital and given nifedipine.", + "Her blood pressure was not controlled.", + "On October 24, 2019, the girl was transferred to our hospital.", + "Physical examination revealed that her blood pressure (BP) was 140/70 mmHg in the left upper limb.", + "Physical examination revealed that her blood pressure (BP) was 139/79 mmHg in the right upper limb.", + "Physical examination revealed that her blood pressure (BP) was 167/76 mmHg in the left lower limb.", + "Physical examination revealed that her blood pressure (BP) was 165/67 mmHg in the right lower limb.", + "Before this, her blood pressure was increased once in a visit in 2017 in the only few outpatient visits.", + "She had painless fixed flexion deformities of multiple joints on physical examination.", + "Ophthalmologic checks showed bilateral band-shaped degeneration of the cornea.", + "She was diagnosed with bilateral panuveitis by an ophthalmologist.", + "Her 24-h urinary protein excretion was 0.19 g.", + "Her serum creatinine was 102 μmol/L.", + "Her renin–angiotensin–aldosterone, CRP, ESR and thyroid hormone were within the normal ranges.", + "Her autoantibodies were negative.", + "Ambulatory blood pressure monitoring (ABPM) showed that the 24-h average BP was 143/83 mmHg.", + "B ultrasound demonstrated that the right kidney was smaller than the left kidney.", + "The difference in length between the two kidneys was 1.35 cm.", + "The sizes of the kidneys did not increase with age.", + "The right kidney gradually decreased in size.", + "The size difference of both kidneys gradually increased.", + "99mTc-DTPA renography demonstrated that the right kidney was smaller than the left kidney with poor renal perfusion and impaired renal function.", + "The GFR [ml·min-1·(1.73 m2)-1] of the kidneys was 74.4.", + "The renal function was 41.4% in the right kidney.", + "The renal function was 58.6% in the left kidney.", + "Computed tomography angiography (CTA) of the renal artery illustrated that the branches of the renal artery in the right hilum had mild stenosis.", + "The right kidney was smaller than the left kidney.", + "The patient was diagnosed with right renal vasculitis through CTA of the renal artery.", + "The diagnosis was likely an autoinflammatory disease.", + "The results revealed that she had a de-novo heterozygous mutation in the NOD2 gene (c.1538 T > C, p.M513T).", + "The M513T (1538 T/C) mutation was a heterozygous mutation and has been reported previously.", + "She was finally diagnosed with Blau syndrome and renovascular hypertension.", + "We suggested treating her with an anti-TNF-α monoclonal antibody (adalimumab).", + "The patient refused the treatment because of financial reasons.", + "She temporarily accepted a low dose of oral prednisolone, MTX, metoprolol and plendil.", + "Her BP was gradually decreased and was controlled at approximately 130/80 mmHg.", + "The OD and OS corrected vision were gradually restored to 0.6 after approximately 3 months.", + "Her serum creatinine level slightly decreased and remained between 80–90 μmol/L after nearly 3 months of follow-up.", + "In February 2020, she was referred to an adult hospital after reaching the age of 18.", + "In the latest telephone consultation with the patient in December 2022, she stated that she was receiving prednisolone (15 mg/day) and tofacitinib (5 mg bid).", + "MTX had been discontinued because of abnormal transaminase.", + "There were no new symptoms in the joints or eyes.", + "There were also no rashes.", + "Hematology examinations indicated that the patient’s ESR (25 mm/h) and serum creatinine (138 μmol/L) had increased.", + "Her blood pressure was maintained at approximately 140/90 mmHg without any antihypertensive therapy." + ], + "summary": "We describe a 20-year-old girl who was initially misdiagnosed with juvenile idiopathic arthritis (JIA) almost 15 years prior. In October 2019, she developed renal arteritis at the age of 17 years and was eventually diagnosed with Blau syndrome. A de-novo M513T mutation was found in her gene testing. A review of the literature on patients with Blau syndrome and vasculitis showed that a total of 18 cases were reported in the past 40 years. The vast majority of them were predominantly involved medium and large vessel arteritis. Of the 18 patients included in our literature review, 14 patients had aorto-arteritis, and 4 of them had renal artery involvement. Two patients presented with renal artery stenosis, 1with a sinus of Valsalva aneurysm, and 1 with retinal vasculitis.", + "summary_subclaims": [ + "The patient was initially misdiagnosed with juvenile idiopathic arthritis almost 15 years prior.", + "In October 2019, she developed renal arteritis at the age of 17 years.", + "She was eventually diagnosed with Blau syndrome.", + "A de-novo M513T mutation was found in her gene testing.", + "A review of the literature on patients with Blau syndrome and vasculitis showed that a total of 18 cases were reported in the past 40 years.", + "The vast majority of them were predominantly involved medium and large vessel arteritis.", + "Of the 18 patients included in our literature review, 14 patients had aorto-arteritis.", + "Four of the 18 patients had renal artery involvement.", + "Two patients presented with renal artery stenosis.", + "One patient had a sinus of Valsalva aneurysm.", + "One patient had retinal vasculitis." + ] + }, + { + "id": "multiclinsum_test_813_en.txt", + "fulltext": "A 51-year-old male patient presented with a 19-day history of redness and pain in the eye. The diagnosis was fungal keratitis . Treatment included frequent instillation of natamycin eye drops (50mg/ml, North China Pharmaceutical, China) and intermittent application of intracorneal voriconazole injection (1mg/ml, Pfizer Limited, US). Following one month of treatment, examination results indicated that the sign of corneal ulcer healing, with no observable progress. However, there was a concerning sign of corneal perforation. . B-ultrasound demonstrated the absence of abnormalities in the vitreous and retina. Consequently, a partial penetrating keratoplasty was performed with a favorable outcome. Intraoperatively, aqueous humor samples and the affected corneal tissue were collected for subsequent culture and identification of bacteria and fungi. Voriconazole injection was used throughout the procedure for corneal margin and anterior chamber irrigation. The donor cornea, sourced from our eye bank, and residual donor cornea, along with corneal preservation solution (Corneal Chamber, Alchimial, Italy), were sent for bacterial and fungal culture postoperatively. The postoperative regimen consisted of local administration of natamycin and tacrolimus eye drops (0.1%, Senju Pharmaceutical Co, Japan), as well as levofloxacin eye drops (0.5%, Senju Pharmaceutical Co, Japan). Additionally, itraconazole capsules (200 mg daily, Xi'an Yangsen Pharmaceutical Co., Ltd., China) were orally administered.\nFollowing corneal transplantation, the graft remained transparent. However, the aqueous humor exhibited gradual turbidity, and by the fourth postoperative day, anterior chamber pus accumulation was observed, prompting concern regarding a potential recurrence of fungal infection. Consequently, the anterior chamber was aspirated to remove the pus, and a voriconazole injection was administered for anterior chamber irrigation and medication. Intraoperatively, it was noted that the anterior chamber pus was thin and watery in consistency, in contrast to the thicker purulent fluid observed in fungal infections. An examination of the anterior chamber pus revealed the absence of fungal hyphae . Postoperatively, there was no significant improvement in the anterior chamber reaction, and the cornea exhibited mild edema.\nA microbiological examination of the recipient corneal ulcer, aqueous humour, donor cornea, and preservation solution yielded negative results for bacteria and fungi, which is thought to be the consequence of preoperative antifungal and antibacterial treatment. However, given the possibility of other infections occurring postoperatively, aqueous humour and anterior chamber pus from the operated eye were collected for metagenomic next-generation sequencing (mNGS) test. Total genomic DNA was extracted using a nucleic acid extraction kit, then fragmented to 200 bp and used to build a library with end-repaired, adapter-ligation, and polymerase chain reaction amplification. The prepared library was sequenced on the MGISEQ-2000 sequencing platform (MGI, China). The reads were finally aligned to the Microbial Genome Databases, which contain the whole-genome sequences of 8,472 viruses, 10,537 bacteria, 903 fungi and 288 parasites. During the aforementioned interval, the previously administered eye drops were maintained. This was accompanied by an increase in the rate of anterior chamber pus leakage, culminating in the clouding of the corneal graft . The mNGS results identified O. anthropi, with 321 sequences with a relative abundance of 98.98%. Additionally, a vitreous opacity was revealed through a B-ultrasound examination. . To treat O. anthropic, ceftazidime (25 mg/ml), an amikacin (4 mg/ml), and vancomycin (10 mg/ml) were administered to the anterior chamber and vitreous, respectively, three times each. The oral antifungal medication was discontinued, and a cefuroxime injection (1.0 g, administered three times a day) was administered intracamerally. To prevent a recurrence of fungal infection, natamycin eye drops were administered four times daily, in conjunction with tobramycin eye drops (0.3%, Tobramycin Eye Drops, Alcon-Couvreur n. v, Belgium), and levofloxacin eye drops (0.5%, Senju Pharmaceutical Co, Japan) at 1-hour intervals. Following three days of treatment, there was a reduction in anterior chamber pus (see Fig. B). After a further ten days of treatment, the anterior chamber pus had been absorbed completely. However, the corneal graft remained cloudy , with ultrasound indicating that the vitreous opacities had reduced . The patient's condition remained stable, with effective infection control being maintained.\nSix months following corneal transplantation, the operated eye exhibited corneal opacities and pseudo-pterygium . B-ultrasound examination did not reveal any abnormalities. To enhance visual function, a secondary partial penetrating keratoplasty was conducted concurrently with a cataract removal procedure. Postoperatively, Tobramycin eye drops were administered for the purpose of prophylaxis against infection, in conjunction with Tacrolimus and Prednisolone Acetate Ophthalmic Suspension (1%, Allergan Pharmaceuticals Ireland) for the prevention of rejection. One month following the procedure, the corneal graft was observed to be transparent, with a corrected visual acuity of 0.1 .", + "fulltext_subclaims": [ + "The patient was a 51-year-old male.", + "The patient had a 19-day history of redness and pain in the eye.", + "The diagnosis was fungal keratitis.", + "Treatment included frequent instillation of natamycin eye drops (50mg/ml, North China Pharmaceutical, China).", + "Intermittent application of intracorneal voriconazole injection (1mg/ml, Pfizer Limited, US) was part of the treatment.", + "Following one month of treatment, corneal ulcer healing was observed.", + "There was no observable progress in the corneal ulcer.", + "There was a concerning sign of corneal perforation.", + "B-ultrasound demonstrated the absence of abnormalities in the vitreous and retina.", + "A partial penetrating keratoplasty was performed.", + "The outcome of the partial penetrating keratoplasty was favorable.", + "Aqueous humor samples and the affected corneal tissue were collected for subsequent culture and identification of bacteria and fungi.", + "Voriconazole injection was used throughout the procedure for corneal margin and anterior chamber irrigation.", + "The donor cornea was sourced from our eye bank.", + "The residual donor cornea and corneal preservation solution were sent for bacterial and fungal culture postoperatively.", + "The postoperative regimen consisted of local administration of natamycin and tacrolimus eye drops (0.1%, Senju Pharmaceutical Co, Japan).", + "The postoperative regimen included levofloxacin eye drops (0.5%, Senju Pharmaceutical Co, Japan).", + "Itraconazole capsules (200 mg daily, Xi'an Yangsen Pharmaceutical Co., Ltd., China) were orally administered.", + "Following corneal transplantation, the graft remained transparent.", + "The aqueous humor exhibited gradual turbidity.", + "By the fourth postoperative day, anterior chamber pus accumulation was observed.", + "The anterior chamber was aspirated to remove the pus.", + "A voriconazole injection was administered for anterior chamber irrigation and medication.", + "The anterior chamber pus was noted to be thin and watery in consistency.", + "An examination of the anterior chamber pus revealed the absence of fungal hyphae.", + "Postoperatively, there was no significant improvement in the anterior chamber reaction.", + "The cornea exhibited mild edema.", + "Microbiological examination of the recipient corneal ulcer, aqueous humour, donor cornea, and preservation solution yielded negative results for bacteria and fungi.", + "The negative microbiological results were thought to be the consequence of preoperative antifungal and antibacterial treatment.", + "Aqueous humour and anterior chamber pus from the operated eye were collected for metagenomic next-generation sequencing (mNGS) test.", + "Total genomic DNA was extracted using a nucleic acid extraction kit.", + "The prepared library was sequenced on the MGISEQ-2000 sequencing platform (MGI, China).", + "The mNGS results identified O. anthropi, with 321 sequences with a relative abundance of 98.98%.", + "A vitreous opacity was revealed through a B-ultrasound examination.", + "Ceftazidime (25 mg/ml), amikacin (4 mg/ml), and vancomycin (10 mg/ml) were administered to the anterior chamber and vitreous, respectively, three times each.", + "The oral antifungal medication was discontinued.", + "A cefuroxime injection (1.0 g, administered three times a day) was administered intracamerally.", + "Natamycin eye drops were administered four times daily.", + "Tobramycin eye drops (0.3%, Tobramycin Eye Drops, Alcon-Couvreur n. v, Belgium) were administered.", + "Levofloxacin eye drops (0.5%, Senju Pharmaceutical Co, Japan) were administered at 1-hour intervals.", + "Following three days of treatment, there was a reduction in anterior chamber pus.", + "After a further ten days of treatment, the anterior chamber pus had been absorbed completely.", + "The corneal graft remained cloudy.", + "Ultrasound indicated that the vitreous opacities had reduced.", + "The patient's condition remained stable.", + "Effective infection control was maintained.", + "Six months following corneal transplantation, the operated eye exhibited corneal opacities and pseudo-pterygium.", + "B-ultrasound examination did not reveal any abnormalities.", + "A secondary partial penetrating keratoplasty was conducted concurrently with a cataract removal procedure.", + "Tobramycin eye drops were administered for the purpose of prophylaxis against infection.", + "Tacrolimus and Prednisolone Acetate Ophthalmic Suspension (1%, Allergan Pharmaceuticals Ireland) were administered for the prevention of rejection.", + "One month following the procedure, the corneal graft was observed to be transparent.", + "The corrected visual acuity was 0.1." + ], + "summary": "A retrospective analysis of cases involved examinations, genetic testing for diagnosis, and subsequent treatment. In patients undergoing partial penetrating keratoplasty with a fungal corneal ulcer perforation, anterior chamber exudation and purulence were observed post-surgery. Despite antifungal treatment, genetic testing of the anterior chamber fluid and purulent material confirmed O. anthropi infection. The use of antimicrobial treatment specifically targeting O. anthropi was found to be effective in treating the infection.", + "summary_subclaims": [ + "A retrospective analysis of cases involved examinations, genetic testing for diagnosis, and subsequent treatment.", + "In patients undergoing partial penetrating keratoplasty with a fungal corneal ulcer perforation, anterior chamber exudation and purulence were observed post-surgery.", + "Despite antifungal treatment, genetic testing of the anterior chamber fluid and purulent material confirmed O. anthropi infection.", + "The use of antimicrobial treatment specifically targeting O. anthropi was found to be effective in treating the infection." + ] + }, + { + "id": "multiclinsum_test_2195_en.txt", + "fulltext": "A 63-year-old, right-handed female presented with new complaints of shortness of breath, nausea, vomiting, and severe progressive headache over the course of 3 weeks. Her past medical history was complicated with a longstanding history of hepatitis C acquired from a blood transfusion in the 1970s. Unfortunately, she developed end-stage liver disease, cirrhosis, PPHTN, and coagulopathy. Her neurologic examination was grossly intact. A computed tomography (CT) scan of the head demonstrated a 13-mm, left-sided lentiform-shaped hyperdensity suggestive of subdural hematoma with midline shift of 7 mm and minimal transtentorial herniation . She had an international normalized ratio (INR) of 1.55 and a platelet level of 47,000/μL. At the time of our consultation, she was undergoing a continuous treprostinil infusion and taking oral sildenafil for PPHTN. The patient was admitted to the intensive care unit (ICU) and medical, hepatology, and pulmonary consultations were sought. Fresh frozen plasma (FFP) and platelets were administered, and she was monitored closely. According to our critical care colleagues, the treprostinil could not be discontinued. Repeat laboratory studies yielded an INR of 1.50 and a platelet level of 90,000/μL. Over the ensuing 10 h, her level of consciousness diminished and she acquired mild right-sided hemiparesis. Most concerning was the development of an enlarged left pupil. Repeat head CT at that time revealed the SDH had increased to a maximum width of 16 mm and midline shift of 9.5 mm .\nShe was taken to the operating room for a left frontotemporoparietal craniotomy and evacuation of the subdural clot. A small, bleeding pial artery that had coagulated was the likely source of the hematoma. Treprostinil infusion and sildenafil were continued throughout the surgery. Intraoperatively, hemostasis was obtained in routine fashion without undue burden from excessive bleeding. The brain was nicely pulsatile at the conclusion of surgery, a patch duraplasty loosely sewn, and the bone flap replaced. Tack-up sutures were used, and a subgaleal drain was left behind. Postoperatively she had an INR of 1.45 and a platelet count of 136,000/μL. She awoke immediately and began following commands. Her anisocoria and weakness improved. She became obtunded several hours after the operation and showed signs of herniation (Glasgow Coma Scale 4). A head CT scan demonstrated a large extra-axial hyperdense fluid collection with a midline shift of 19 mm in the same location as the SDH . She was taken emergently to the operating room for reopening of the craniotomy and evacuation of the hematoma. On repeat operation hemostasis was more challenging. The scalp, temporalis muscle, and external dural surface were hemorrhaging diffusely. The hematoma was found in the epidural space, and it was evacuated. There was no significant blood in the subdural space. The coagulopathy was felt to be qualitative, and cryoprecipitate, FFP, and additional platelets were administered in an effort to obtain hemostasis. Various techniques and products including bipolar electrocautery, irrigation, thrombin-soaked Gelfoam® (Pfizer), Gelfoam Powder® (Pfizer), Avitene™ (Davol, Inc.), and Floseal Hemostatic Matrix (Baxter BioSurgery) were utilized to stop the bleeding. At the conclusion of the case the brain was again found to be pulsatile and the decision was made not to replace the bone flap. Subdural and subgaleal drains were placed and the wound was closed using a 2-0 Vicryl™ (Ethicon) on a CT-1 needle and then stapled. In the first hours postoperatively, she began to follow commands and move all of her extremities with strength. Her treprostinil and sildenafil were continued.\nA postoperative CT scan demonstrated resolution of midline shift and some persistent fluid within the operative bed . Her INR measured between 1.4 and 1.7 throughout the remainder of her hospital stay, which lasted just over 1 month. Platelet counts remained between 45,000 and 225,000/μL. Multiple platelet function assays demonstrated dysfunctional platelets while on treprostinil infusion therapy. She was weaned from the ventilator and began to eat. Given her acute medical condition she was no longer a candidate for liver transplant. Over the course of several weeks in the hospital she was weaned from the treprostinil infusion and the tunneled infusion catheter removed. She was transferred to inpatient rehabilitation and eventually was discharged home. Her 2-month postoperative scan showed resolution of fluid in the operative bed . She underwent cranioplasty roughly 6 months after the initial surgery . At that time, she had stable mild right hemiparesis and was ambulatory with a walker. Currently, she is being considered for rechallenge with treprostinil therapy as a bridge to liver transplant.", + "fulltext_subclaims": [ + "The patient is a 63-year-old, right-handed female.", + "She presented with new complaints of shortness of breath, nausea, vomiting, and severe progressive headache over the course of 3 weeks.", + "She has a longstanding history of hepatitis C acquired from a blood transfusion in the 1970s.", + "She developed end-stage liver disease, cirrhosis, PPHTN, and coagulopathy.", + "Her neurologic examination was grossly intact.", + "A CT scan of the head demonstrated a 13-mm, left-sided lentiform-shaped hyperdensity suggestive of subdural hematoma.", + "The CT scan showed a midline shift of 7 mm and minimal transtentorial herniation.", + "Her international normalized ratio (INR) was 1.55.", + "Her platelet level was 47,000/μL.", + "She was undergoing a continuous treprostinil infusion and taking oral sildenafil for PPHTN.", + "She was admitted to the ICU.", + "Medical, hepatology, and pulmonary consultations were sought.", + "Fresh frozen plasma (FFP) and platelets were administered.", + "Repeat laboratory studies yielded an INR of 1.50 and a platelet level of 90,000/μL.", + "Over the ensuing 10 h, her level of consciousness diminished.", + "She acquired mild right-sided hemiparesis.", + "She developed an enlarged left pupil.", + "Repeat head CT at that time revealed the SDH had increased to a maximum width of 16 mm.", + "The midline shift was 9.5 mm.", + "She was taken to the operating room for a left frontotemporoparietal craniotomy and evacuation of the subdural clot.", + "A small, bleeding pial artery that had coagulated was the likely source of the hematoma.", + "Treprostinil infusion and sildenafil were continued throughout the surgery.", + "Intraoperatively, hemostasis was obtained in routine fashion without undue burden from excessive bleeding.", + "The brain was nicely pulsatile at the conclusion of surgery.", + "A patch duraplasty was loosely sewn.", + "The bone flap was replaced.", + "Tack-up sutures were used.", + "A subgaleal drain was left behind.", + "Postoperatively she had an INR of 1.45 and a platelet count of 136,000/μL.", + "She awoke immediately and began following commands.", + "Her anisocoria and weakness improved.", + "She became obtunded several hours after the operation.", + "She showed signs of herniation (Glasgow Coma Scale 4).", + "A head CT scan demonstrated a large extra-axial hyperdense fluid collection with a midline shift of 19 mm in the same location as the SDH.", + "She was taken emergently to the operating room for reopening of the craniotomy and evacuation of the hematoma.", + "On repeat operation hemostasis was more challenging.", + "The scalp, temporalis muscle, and external dural surface were hemorrhaging diffusely.", + "The hematoma was found in the epidural space, and it was evacuated.", + "There was no significant blood in the subdural space.", + "The coagulopathy was felt to be qualitative.", + "Cryoprecipitate, FFP, and additional platelets were administered in an effort to obtain hemostasis.", + "Various techniques and products including bipolar electrocautery, irrigation, thrombin-soaked Gelfoam® (Pfizer), Gelfoam Powder® (Pfizer), Avitene™ (Davol, Inc.), and Floseal Hemostatic Matrix (Baxter BioSurgery) were utilized to stop the bleeding.", + "At the conclusion of the case the brain was again found to be pulsatile.", + "The decision was made not to replace the bone flap.", + "Subdural and subgaleal drains were placed.", + "The wound was closed using a 2-0 Vicryl™ (Ethicon) on a CT-1 needle and then stapled.", + "In the first hours postoperatively, she began to follow commands and move all of her extremities with strength.", + "Her treprostinil and sildenafil were continued.", + "A postoperative CT scan demonstrated resolution of midline shift.", + "There was some persistent fluid within the operative bed.", + "Her INR measured between 1.4 and 1.7 throughout the remainder of her hospital stay.", + "Platelet counts remained between 45,000 and 225,000/μL.", + "Multiple platelet function assays demonstrated dysfunctional platelets while on treprostinil infusion therapy.", + "She was weaned from the ventilator and began to eat.", + "Given her acute medical condition she was no longer a candidate for liver transplant.", + "She was weaned from the treprostinil infusion and the tunneled infusion catheter removed.", + "She was transferred to inpatient rehabilitation.", + "She was eventually discharged home.", + "Her 2-month postoperative scan showed resolution of fluid in the operative bed.", + "She underwent cranioplasty roughly 6 months after the initial surgery.", + "At that time, she had stable mild right hemiparesis and was ambulatory with a walker.", + "She is being considered for rechallenge with treprostinil therapy as a bridge to liver transplant." + ], + "summary": "A 63-year-old, right-handed female with a history of PPHTN presented with severe headache and was found to have a large left aSDH with midline shift on imaging. She was admitted to the neurosurgical intensive care unit (ICU) where she developed hemiparesis and subsequently underwent emergent decompression. Postoperatively she improved, but several hours after became obtunded and imaging showed reaccumulation of the aSDH, which required reoperation. At 6 months postoperatively she had only a mild hemiparesis and was being reconsidered for treprostinil therapy as a bridge to liver transplant. Only one paper in the literature thus far has reported a patient with an aSDH managed with treprostinil. The authors achieved adequate intraoperative hemostasis without the use of platelet transfusion and lack of complications intraoperatively.", + "summary_subclaims": [ + "The patient is a 63-year-old, right-handed female.", + "The patient has a history of PPHTN.", + "The patient presented with severe headache.", + "Imaging showed a large left aSDH with midline shift.", + "The patient was admitted to the neurosurgical ICU.", + "The patient developed hemiparesis.", + "The patient underwent emergent decompression.", + "Postoperatively, the patient improved.", + "Several hours after surgery, the patient became obtunded.", + "Imaging showed reaccumulation of the aSDH.", + "The patient required reoperation.", + "At 6 months postoperatively, the patient had only a mild hemiparesis.", + "The patient was being reconsidered for treprostinil therapy as a bridge to liver transplant.", + "Only one paper in the literature has reported a patient with an aSDH managed with treprostinil.", + "The authors achieved adequate intraoperative hemostasis.", + "The authors did not use platelet transfusion.", + "There was a lack of complications intraoperatively." + ] + }, + { + "id": "multiclinsum_test_799_en.txt", + "fulltext": "A 58-year-old woman with metastatic HR+, HER2- breast cancer presented to the ED with a 3-day history of nausea and vomiting, dyspnea, rash, and blood glucose of 319 mg/dL. Her medical history included type 2 diabetes for which she took empagliflozin, metformin/sitagliptin, and gliclazide. A few weeks prior, molecular profiling revealed the presence of a PIK3CA gene mutation, and she started fulvestrant and alpelisib. Her metastatic breast cancer had already progressed on endocrine and chemotherapy treatment. At that time, self-recorded fasting blood glucose readings were 180–216 mg/dL, and HbA1c was 7.7% (61 mmol/mol). The patient was instructed to monitor blood glucose levels frequently. If glucose levels persistently increased, we would refer her to endocrinology for further management. A follow-up assessment occurred one week after alpelisib initiation, in which the patient reported weight loss of 2–3 kg, decreased appetite, and blood glucose readings ranging from 190 to 306 mg/dL. Before she could return for another follow-up, she began to vomit and presented to the ED three days later.\nOn presentation to the ED, the patient demonstrated dyspnea, nausea and vomiting, and a generalized maculopapular rash on her torso. Labs reported anion gap: 36 mEq/L, pH: 6.99, total CO2: 6 mEq/L, glucose: 402 mg/dL, ketonemia and ketonuria. The patient was admitted to the hospital and started on an insulin sliding scale. Empagliflozin was thought to be a possible cause of the DKA by the ED team and was discontinued. Because alpelisib was recently started and implicated for the rash, it was also held during admission. The patient’s condition worsened overnight, and she was transferred to the ICU. She received bicarbonate infusion and intravenous insulin as per the institutional DKA protocol. Upon resolution of the DKA, she was discharged six days after presentation to the ER. At that time, her gliclazide dose was increased to compensate for the discontinuation of empagliflozin.\nTwo weeks later, the patient returned to the oncology clinic to restart alpelisib. At the time of restarting alpelisib, her blood glucose levels had returned to baseline (180–216 mg/dL). To circumvent the rash development, she was instructed to take desloratadine 10 mg once daily starting two days before the first dose of alpelisib. Four hours after her first alpelisib dose, she returned to the ED. She described feeling unwell one hour after taking alpelisib and experienced emesis, dysphagia, and a pruritic rash on her abdomen, back, and thighs. Her self-monitored blood glucose readings indicated a rapid rise from 198 mg/dL to 306 mg/dL shortly after alpelisib administration. The patient was also febrile. Labs in the ED revealed anion gap: 20 mEq/L, CO2: 21 mEq/L, glucose: 397 mg/dL with ketonemia and ketonuria. She was diagnosed with diabetic ketoacidosis, rash secondary to alpelisib, and possible pneumonia. She was started on DKA insulin protocol and antibiotics empirically. The next morning, the patient was transitioned to subcutaneous insulin and maintained on her diabetic medications as per admission. She defervesced quickly, and blood and urine cultures remained negative for infection. Her rash improved within days of alpelisib discontinuation. Endocrinology was consulted, and they started basal insulin with supplemental mealtime insulin. Alpelisib and gliclazide were discontinued. She was discharged six days after admission. Following her discharge, she did not have any further hyperglycemic complications.", + "fulltext_subclaims": [ + "The patient is a 58-year-old woman with metastatic HR+, HER2- breast cancer.", + "She presented to the ED with a 3-day history of nausea and vomiting.", + "She had a blood glucose of 319 mg/dL.", + "Her medical history included type 2 diabetes.", + "She took empagliflozin, metformin/sitagliptin, and gliclazide.", + "Molecular profiling revealed the presence of a PIK3CA gene mutation.", + "She started fulvestrant and alpelisib.", + "Her metastatic breast cancer had already progressed on endocrine and chemotherapy treatment.", + "Self-recorded fasting blood glucose readings were 180–216 mg/dL.", + "HbA1c was 7.7% (61 mmol/mol).", + "She was instructed to monitor blood glucose levels frequently.", + "If glucose levels persistently increased, she would be referred to endocrinology.", + "A follow-up assessment occurred one week after alpelisib initiation.", + "She reported weight loss of 2–3 kg.", + "She reported blood glucose readings ranging from 190 to 306 mg/dL.", + "She began to vomit and presented to the ED three days later.", + "On presentation to the ED, she demonstrated dyspnea, nausea and vomiting, and a generalized maculopapular rash on her torso.", + "Labs reported an anion gap of 36 mEq/L.", + "Labs reported a pH of 6.99.", + "Labs reported total CO2 of 6 mEq/L.", + "Labs reported glucose of 402 mg/dL.", + "Labs reported ketonemia and ketonuria.", + "The patient was admitted to the hospital and started on an insulin sliding scale.", + "Empagliflozin was thought to be a possible cause of the DKA by the ED team.", + "Empagliflozin was discontinued.", + "Alpelisib was held during admission.", + "She was transferred to the ICU.", + "She received bicarbonate infusion.", + "She received intravenous insulin as per the institutional DKA protocol.", + "She was discharged six days after presentation to the ER.", + "Her gliclazide dose was increased to compensate for the discontinuation of empagliflozin.", + "Two weeks later, she returned to the oncology clinic to restart alpelisib.", + "At the time of restarting alpelisib, her blood glucose levels had returned to baseline (180–216 mg/dL).", + "She was instructed to take desloratadine 10 mg once daily starting two days before the first dose of alpelisib.", + "Four hours after her first alpelisib dose, she returned to the ED.", + "She described feeling unwell one hour after taking alpelisib.", + "She experienced emesis, dysphagia, and a pruritic rash on her abdomen, back, and thighs.", + "Her self-monitored blood glucose readings indicated a rapid rise from 198 mg/dL to 306 mg/dL shortly after alpelisib administration.", + "She was febrile.", + "Labs in the ED revealed an anion gap of 20 mEq/L.", + "Labs in the ED revealed CO2 of 21 mEq/L.", + "Labs in the ED revealed glucose of 397 mg/dL with ketonemia and ketonuria.", + "She was diagnosed with diabetic ketoacidosis.", + "She was diagnosed with rash secondary to alpelisib.", + "She was diagnosed with possible pneumonia.", + "She was started on DKA insulin protocol.", + "She was started on empirical antibiotics.", + "The next morning, she was transitioned to subcutaneous insulin.", + "She was maintained on her diabetic medications as per admission.", + "She defervesced quickly.", + "Blood and urine cultures remained negative for infection.", + "Her rash improved within days of alpelisib discontinuation.", + "Endocrinology was consulted.", + "They started basal insulin with supplemental mealtime insulin.", + "Alpelisib and gliclazide were discontinued.", + "She was discharged six days after admission.", + "Following her discharge, she did not have any further hyperglycemic complications." + ], + "summary": "A case is presented on a patient with metastatic breast cancer and type 2 diabetes admitted for DKA eleven days after starting alpelisib. Since DKA is implicated in antihyperglycemics that inhibit sodium-glucose cotransporter-2 (SGLT2) inhibitors, her empagliflozin was discontinued. Alpelisib was also held since it was recently initiated. After the DKA resolved, she was discharged and restarted alpelisib. Within 4 hours of taking the first dose, the patient developed a second episode of DKA, and alpelisib treatment was stopped permanently.", + "summary_subclaims": [ + "The patient had metastatic breast cancer.", + "The patient had type 2 diabetes.", + "The patient was admitted for DKA.", + "The DKA occurred eleven days after starting alpelisib.", + "Her empagliflozin was discontinued.", + "Alpelisib was held since it was recently initiated.", + "After the DKA resolved, she was discharged.", + "She was restarted on alpelisib.", + "Within 4 hours of taking the first dose, the patient developed a second episode of DKA.", + "Alpelisib treatment was stopped permanently." + ] + }, + { + "id": "multiclinsum_test_107_en.txt", + "fulltext": "An 18-year-old male, healthy collegiate sprinter, presented with a chronic tear of his right rectus femoris tendon. A year prior, he was running high school track when he felt a pop in his right thigh and developed an obvious deformity. Physical therapy was attempted with incomplete recovery and continued thigh and groin pain, resulting in an occasional antalgic gait. He also felt subjective limitation in his athletic ability. Due to his continued symptoms, he sought a second opinion with the primary investigator.\nPhysical examination of the thigh demonstrated an obvious subcutaneous deformity, similar to a “Popeye” type sign seen in the proximal biceps, with a palpable defect in the quadriceps tendon. Knee range of motion was 0–120° and he was tender to palpation along the distal tendon stump. Hip range of motion was 110° of flexion, 15° of extension, 35° of internal rotation, and 45° of external rotation. Internal impingement sign was positive reproducing the patient’s pain in his groin.\nMRI of the right lower extremity and MR arthrogram of the right hip demonstrated a complete tear of the rectus femoris tendon without atrophic changes, a CAM lesion with an alpha angle of 70°, and anterior-superior labrum tearing.\nA trial of conservative management was attempted with activity modification, physical therapy, and an intra-articular hip injection for both diagnostic and therapeutic purposes. With the injection, we attempted to isolate the patient’s symptoms as coming from intra-articular hip pathology or from the rectus femoris rupture. The injection relieved his groin pain for approximately 1 week with continued irritation in the thigh, especially isolated around the tendon stump. An attempt was made with the patient to elucidate the true nature of the symptoms. He sincerely felt that the groin pain, which was temporarily relieved from the injection, was significant and independent pain from the pain, he experienced at the region of the tendon stump. The pain at the tendon stump continued to bother him during the week of relief from the groin pain. Furthermore, after the initial response to the injection, the patient felt that both areas of pain were significant to his overall limitations and symptoms. At this point, the patient had failed conservative therapy with both the intra-articular pathology and rectus femoris rupture deemed significant sources of his persistent symptoms. Surgery was recommended for both hip and tendon pathologies.\nThe primary surgeon and patient jointly decided to address the rectus femoris rupture with reconstruction and the intra-articular hip pathologies through hip arthroscopy. For the rectus femoris, the patient was positioned supine on a traction table. A midline incision, in line with the quadriceps tendon, was made at the site of tendon rupture from the tendon stump to the proximal patella. The distal stump of the rectus femoris was isolated circumferentially. There was approximately 4 mm of relatively thin rectus femoris tendon stump remaining. The tendon stump was sutured with multiple loops of Fiberwire (Arthrex, Naples, FL). The Achilles allograft was then obtained and sutured medially and laterally in a running Krackow fashion. The Achilles graft was fanned out and tacked to the rectus femoris muscle belly utilizing approximately 15 simple interrupted #2 Ethibond (Ethicon, Cincinnati, OH) sutures. Fiberwire (Arthrex, Naples FL) was utilized to connect the tendon graft to the remaining rectus femoris tendon stump in a Krakow fashion medially and laterally. Attempting to balance anatomic location versus graft/tendon tension, the rectus femoris complex was pulled over the distal intact quadriceps tendon. While maintaining tension, #2 Fiberwire (Arthrex, Naples, FL) was passed in a running Krakow fashion medially and laterally through the graft and quadriceps tendon from musculotendinous margin to the proximal patella and back. Once completed, the graft and rectus femoris had excellent stability throughout knee range of motion.\nFor the hip arthroscopic procedure, the hip was placed under traction. Three portals were utilized: Anterolateral, mid-anterior, and distal anterolateral accessory. Diagnostic arthroscopy demonstrated a labral tear from the 12:30 to 3:00 position. The acetabular rim was decorticated. For the 1:00 position and 2:30 position, knotless Cinchlock anchors (Stryker, Kalamazoo, MI) were utilized to affix the labrum. Traction was then released and restoration of the suction seal nature of the labrum was confirmed. Attention was then turned to the arthroscopic femoroplasty. The convex protuberance of bone consistent with a CAM lesion was noted at the 1–3 o’clock position. A burr was used to recontour the femoral head-and-neck junction to a concave structure. This was confirmed by direct visualization and intraoperative radiographs.\nFollowing the arthroscopic procedure, the rectus femoris reconstruction was rechecked and intact. All skin incisions were then closed and dressed.\nPostoperatively, the patient was placed in a locked knee immobilizer and recommend toe-touch weightbearing for 3 weeks. Physical therapy was initiated after 2 weeks with a gradual progression of weightbearing after 3 weeks. Knee flexion was initiated at 2 weeks with 15 degrees per week until full motion. No quadriceps resistance was allowed until 3 months. Six months following the operation, the patient was cleared to return to sports. There were no complications encountered.", + "fulltext_subclaims": [ + "The patient is an 18-year-old male.", + "He is a collegiate sprinter.", + "He has a chronic tear of his right rectus femoris tendon.", + "A year prior, he felt a pop in his right thigh.", + "He developed an obvious deformity.", + "Physical therapy was attempted.", + "He had incomplete recovery.", + "He had continued thigh and groin pain.", + "He had an occasional antalgic gait.", + "He felt subjective limitation in his athletic ability.", + "Physical examination demonstrated an obvious subcutaneous deformity.", + "The deformity was similar to a “Popeye” type sign seen in the proximal biceps.", + "There was a palpable defect in the quadriceps tendon.", + "Knee range of motion was 0–120°.", + "He was tender to palpation along the distal tendon stump.", + "Hip range of motion was 110° of flexion.", + "Hip range of motion was 15° of extension.", + "Hip range of motion was 35° of internal rotation.", + "Hip range of motion was 45° of external rotation.", + "The internal impingement sign was positive.", + "MRI demonstrated a complete tear of the rectus femoris tendon.", + "MRI showed no atrophic changes.", + "MRI showed a CAM lesion with an alpha angle of 70°.", + "MRI showed anterior-superior labrum tearing.", + "A trial of conservative management was attempted.", + "An intra-articular hip injection was performed.", + "The injection relieved his groin pain for approximately 1 week.", + "He had continued irritation in the thigh.", + "He felt that the groin pain was significant and independent.", + "The pain at the tendon stump continued to bother him.", + "The patient had failed conservative therapy.", + "The rectus femoris rupture was deemed a significant source of his symptoms.", + "Surgery was recommended for both hip and tendon pathologies.", + "The patient and surgeon decided to address the rectus femoris rupture with reconstruction.", + "The patient was positioned supine on a traction table.", + "A midline incision was made at the site of tendon rupture.", + "The distal stump of the rectus femoris was isolated.", + "There was approximately 4 mm of relatively thin rectus femoris tendon stump remaining.", + "The tendon stump was sutured with multiple loops of Fiberwire.", + "An Achilles allograft was obtained.", + "The Achilles graft was sutured medially and laterally in a running Krackow fashion.", + "The Achilles graft was fanned out and tacked to the rectus femoris muscle belly.", + "Approximately 15 simple interrupted #2 Ethibond sutures were used.", + "Fiberwire was utilized to connect the tendon graft to the remaining rectus femoris tendon stump.", + "The rectus femoris complex was pulled over the distal intact quadriceps tendon.", + "#2 Fiberwire was passed in a running Krakow fashion through the graft and quadriceps tendon.", + "The graft and rectus femoris had excellent stability throughout knee range of motion.", + "The hip was placed under traction.", + "Three portals were utilized: Anterolateral, mid-anterior, and distal anterolateral accessory.", + "Diagnostic arthroscopy demonstrated a labral tear from the 12:30 to 3:00 position.", + "The acetabular rim was decorticated.", + "Knotless Cinchlock anchors were utilized to affix the labrum.", + "Traction was released.", + "Restoration of the suction seal nature of the labrum was confirmed.", + "A burr was used to recontour the femoral head-and-neck junction.", + "The rectus femoris reconstruction was rechecked and intact.", + "All skin incisions were closed and dressed.", + "The patient was placed in a locked knee immobilizer.", + "Toe-touch weightbearing was recommended for 3 weeks.", + "Physical therapy was initiated after 2 weeks.", + "Knee flexion was initiated at 2 weeks.", + "No quadriceps resistance was allowed until 3 months.", + "The patient was cleared to return to sports 6 months following the operation.", + "There were no complications encountered." + ], + "summary": "We describe an 18-year-old collegiate sprinter with a rectus femoris tendon rupture who continued to have significant pain and dysfunction despite non-operative management. He was concurrently found to have femoroacetabular impingement and a labrum tear as well. Following an extensive trial of non-operative management, operative fixation of the rectus femoris rupture with Achilles allograft reconstruction was performed in addition to arthroscopic labrum fixation and femoroplasty. Postoperatively, he returned to sport with improved mobility and decreased pain.", + "summary_subclaims": [ + "The patient is an 18-year-old collegiate sprinter.", + "The patient had a rectus femoris tendon rupture.", + "The patient had significant pain and dysfunction despite non-operative management.", + "The patient was found to have femoroacetabular impingement.", + "The patient was found to have a labrum tear.", + "An extensive trial of non-operative management was attempted.", + "Operative fixation of the rectus femoris rupture was performed.", + "Achilles allograft reconstruction was performed.", + "Arthroscopic labrum fixation was performed.", + "Femoroplasty was performed.", + "Postoperatively, the patient returned to sport.", + "The patient had improved mobility postoperatively.", + "The patient had decreased pain postoperatively." + ] + }, + { + "id": "multiclinsum_test_2166_en.txt", + "fulltext": "A 35-year-old G2P0010 Cameroonian student at 39-weeks pregnancy was referred to the surgical unit of the Yaounde Gynaeco-Obstetrics and Paediatric Hospital for the management of a strangulated umbilical hernia. She had a sudden onset of localized umbilical pain three hours prior to consultation. The pain was of moderate intensity, crampy in character, aggravated by walking, without any change in bowel movement and no vomiting. An abdominal ultrasound scan revealed a parietal defect of the umbilicus measuring 55 mm in diameter with a poorly vascularised hypoechoic mass (doppler scan) measuring 50 × 30 × 37 mm, 29.6 ml in volume. In addition, the foetus was viable with a normal biophysical score and a good concordance between clinical and sonographic dating of gestational age. Hence, she was referred for surgical management of a strangulated umbilical hernia in a term pregnancy.\nAn episode of severe malaria during her previous pregnancy was at the origin of a spontaneous abortion at 10 weeks of gestation. Her current pregnancy was being followed at the Efoulan District hospital in Yaounde where she had attended six antenatal clinics. A urine dipstick at 24 weeks of gestation revealed a proteinuria of 600 mg/l coupled with an increase blood pressure to 152/98 mmHg and the development of lower limb oedema. She was diagnosed with pre-ecclampsia and placed on alphamethyldopa 250 mg twice daily. A second trimester ultrasound revealed the presence of two anterior and posterior interstitial myomatous nuclei, of 51 mm and 73 mm long axis respectively.\nOn physical examination, the patient was in severe pain (visual analogue scale of 9/10 cm) with a temperature of 38.1 °C, pulse rate of 112 beats per minutes, respiratory rate of 22 breaths per minutes and blood pressure of 170/118 mmHg. Abdominal examination showed a gravid uterus with a uterine fundal height of 38 cm. There was a tender, non-reducible umbilical swelling , with no cough impulse. There was no sign of peritoneal irritation. She had no costovertebral angle tenderness. Bowel sounds were present and normal. Her digital rectal examination was unremarkable. The foetus had a longitudinal lie, cephalic presentation, right-occipito anterior position and a fetal heart rate of 140 beats per minute. On vaginal examination, the cervix was posterior, non-effaced and closed. She had a bilateral pitting lower limb oedema extending to both knees. In view of this clinical picture, we thought of a strangulated umbilical hernia. All of these on a probable background of severe pre-eclampsia. The laboratory panel requested on admission is illustrated in Table .\nA multidisciplinary team involving general surgeons, obstetricians and anaesthesiologists decided on a two-in one intervention wherby an emergency ceaseraean section with indication severe pre-ecclampsia, and a herniorraphy with indication strangulated umbilical hernia will be carried out within the same operation. Preoperative management consisted of placing two peripheral venous lines of large bore needle with infusion of 1000 ml of normal saline, parenteral administration of an analgesic (paracetamol 1 g), an antihypertensive drug (nicardipine 2 mg bolus) and anticonvulsant (magnesium sulphate 5 g intravenously followed by 4 g intramuscularly in each gluteus muscles). A Pfannenstiel incision performed five hours after admission permitted the extraction of a life female baby who weighed 3300 g at birth with an APGAR score of 8 and 10 at the first and fifth minutes respectively. Intraoperative findings of an anterior and posterior sub-serosal leiomyomas both measuring about 50 mm ; anterior fibroid had an axis pointing to the umbilical ring, with irregular contours and a heterogeneous center, strongly suggestive of aseptic necrobiosis. In addition, the uterus also had several interstitial myomas. The uterine adnexae and the appendix were macroscopically normal. The herniated omentum was not necrosed. No intestines necrosis was observed. Both sub-serosal leiomyomas were surgically excised and sent for histo-pathological evaluation. A separate arciform infra-umbilical incision permitted repair of the umbilical hernia.\nHistopathological analysis of the leiomyoma samples was consistent with red degeneration (aseptic necrobiosis) of the excised uterine fibroid . The postoperative outcome was uneventful for both the mother and the baby, with the former resuming progressive oral feeding on the first postoperative day. She was discharged five days later in a good clinical condition. Her follow-up at six weeks postoperatively was uneventful.. The six-month postoperative course was also normal.", + "fulltext_subclaims": [ + "The patient is a 35-year-old G2P0010 Cameroonian student.", + "She was referred to the surgical unit of the Yaounde Gynaeco-Obstetrics and Paediatric Hospital.", + "She was referred for the management of a strangulated umbilical hernia.", + "She had a sudden onset of localized umbilical pain three hours prior to consultation.", + "The pain was of moderate intensity.", + "The pain was crampy in character.", + "The pain was aggravated by walking.", + "There was no change in bowel movement.", + "There was no vomiting.", + "An abdominal ultrasound scan revealed a parietal defect of the umbilicus measuring 55 mm in diameter.", + "The ultrasound scan showed a poorly vascularised hypoechoic mass measuring 50 × 30 × 37 mm.", + "The mass had a volume of 29.6 ml.", + "The foetus was viable.", + "The foetus had a normal biophysical score.", + "There was a good concordance between clinical and sonographic dating of gestational age.", + "She was referred for surgical management of a strangulated umbilical hernia in a term pregnancy.", + "An episode of severe malaria during her previous pregnancy was at the origin of a spontaneous abortion at 10 weeks of gestation.", + "Her current pregnancy was being followed at the Efoulan District hospital in Yaounde.", + "She had attended six antenatal clinics.", + "A urine dipstick at 24 weeks of gestation revealed a proteinuria of 600 mg/l.", + "Her blood pressure was 152/98 mmHg at 24 weeks of gestation.", + "She developed lower limb oedema.", + "She was diagnosed with pre-ecclampsia.", + "She was placed on alphamethyldopa 250 mg twice daily.", + "A second trimester ultrasound revealed the presence of two anterior and posterior interstitial myomatous nuclei.", + "The myomatous nuclei measured 51 mm and 73 mm long axis respectively.", + "On physical examination, the patient was in severe pain with a visual analogue scale of 9/10 cm.", + "Her temperature was 38.1 °C.", + "Her pulse rate was 112 beats per minute.", + "Her respiratory rate was 22 breaths per minute.", + "Her blood pressure was 170/118 mmHg.", + "Abdominal examination showed a gravid uterus with a uterine fundal height of 38 cm.", + "There was a tender, non-reducible umbilical swelling.", + "There was no cough impulse.", + "There was no sign of peritoneal irritation.", + "The foetus had a longitudinal lie.", + "The foetus had a cephalic presentation.", + "The foetus had a right-occipito anterior position.", + "The fetal heart rate was 140 beats per minute.", + "The cervix was posterior, non-effaced, and closed.", + "She had bilateral pitting lower limb oedema extending to both knees.", + "The clinical picture was suggestive of a strangulated umbilical hernia.", + "The clinical picture was on a probable background of severe pre-eclampsia.", + "A multidisciplinary team decided on a two-in-one intervention.", + "The intervention included an emergency caesarean section with indication severe pre-ecclampsia.", + "The intervention included a herniorraphy with indication strangulated umbilical hernia.", + "Preoperative management included placing two peripheral venous lines of large bore needle.", + "Preoperative management included infusion of 1000 ml of normal saline.", + "Preoperative management included parenteral administration of paracetamol 1 g.", + "Preoperative management included parenteral administration of nicardipine 2 mg bolus.", + "Preoperative management included parenteral administration of magnesium sulphate 5 g intravenously.", + "Preoperative management included parenteral administration of magnesium sulphate 4 g intramuscularly in each gluteus muscle.", + "A Pfannenstiel incision performed five hours after admission permitted the extraction of a live female baby.", + "The baby weighed 3300 g at birth.", + "The baby had an APGAR score of 8 at the first minute.", + "The baby had an APGAR score of 10 at the fifth minute.", + "Intraoperative findings included an anterior and posterior sub-serosal leiomyomas both measuring about 50 mm.", + "The anterior fibroid had an axis pointing to the umbilical ring.", + "The anterior fibroid had irregular contours.", + "The anterior fibroid had a heterogeneous center.", + "The anterior fibroid was strongly suggestive of aseptic necrobiosis.", + "The uterus also had several interstitial myomas.", + "The uterine adnexae were macroscopically normal.", + "The appendix was macroscopically normal.", + "The herniated omentum was not necrosed.", + "No intestinal necrosis was observed.", + "Both sub-serosal leiomyomas were surgically excised.", + "The leiomyoma samples were sent for histopathological evaluation.", + "A separate arciform infra-umbilical incision permitted repair of the umbilical hernia.", + "Histopathological analysis of the leiomyoma samples was consistent with red degeneration.", + "The postoperative outcome was uneventful for both the mother and the baby.", + "The mother resumed progressive oral feeding on the first postoperative day.", + "She was discharged five days later in a good clinical condition.", + "Her six-week postoperative follow-up was uneventful.", + "Her six-month postoperative course was also normal." + ], + "summary": "A term pregnant Cameroonian woman was admitted to our maternity unit with clinical findings suggestive of a strangulated umbilical hernia. She underwent an emergency caesarean section which fortuitously revealed aseptic necrobiosis of a uterine fibroid, managed within the same surgical intervention by myomectomy. Her post-operative course was uneventful.", + "summary_subclaims": [ + "A term pregnant Cameroonian woman was admitted to our maternity unit with clinical findings suggestive of a strangulated umbilical hernia.", + "She underwent an emergency caesarean section.", + "The emergency caesarean section fortuitously revealed aseptic necrobiosis of a uterine fibroid.", + "The aseptic necrobiosis of the uterine fibroid was managed within the same surgical intervention by myomectomy.", + "Her post-operative course was uneventful." + ] + }, + { + "id": "multiclinsum_test_2114_en.txt", + "fulltext": "Our patient was a 39-year-old Chinese woman who had delivered a second live full-term infant through an uncomplicated cesarean section in 2011 after a miscarriage in 2010 and a first cesarean section in 2005. In December 2014, she noticed a purple, nontender swelling appearing as an anterior abdominal wall mass around her cesarean scar. The mass was the size of a green bean and was not accompanied by any abdominal pain or abnormal vaginal bleeding. There were no notable findings in her past medical history, family history, or psychosocial history. The abdominal wall mass had progressively enlarged, which led to her presentation to a local institution. She had undergone tumor resection of the abdominal wall in June 2015, which might be interpreted as the abdominal wall endometriosis malignancy.\nThe patient had visited a regional tertiary hospital for a consultation regarding the pathologic diagnosis of a CC before presenting to our hospital for further diagnosis and treatment. Her physical examination showed no abnormalities except for the scar from the local excision on the abdominal wall. Our pathologists reviewed the first excised specimen from the previous hospital and confirmed the characteristic of CC coexisting with minor ETT. Her Ki-67 proliferative index was approximately 50%. Laboratory analysis revealed normal serum levels of β-human chorionic gonadotropin (β-hCG; < 1.2 IU/L) and tumor markers, including carbohydrate antigen 125 (CA 125), carcinoembryonic antigen (CEA), CA 19-9, CA 15-3, and α-fetoprotein; all of these biomarkers had consistently negative values. Positron emission tomography was performed to further determine whether other metastatic lesions existed; however, no residual tumor and suspicious malignant lesions were observed. For further evaluation, endometrial curettage was performed, the results of which revealed normal menstrual phase endometrium. Subsequently, the patient received two courses of chemotherapy with a regimen of etoposide and cisplatin (EP) over a 2-month period. During chemotherapy, her serum β-hCG levels remained negative (< 1.2 IU/L).\nSubsequently, she underwent regular follow-up in the outpatient department, and a recurrent nodule was found on the same abdominal wall scar site in January 2017, approximately 17 months after the last chemotherapy. The patient was registered for admission again. Her serum β-hCG had increased to 6.17 IU/L, and two oval hypoechoic masses were visualized by ultrasonography in the subcutaneous soft tissue of the lower abdomen wall scar. Chest computed tomography (CT) and head magnetic resonance imaging (MRI) showed no abnormality. Then she underwent a second notable mass excision by ultrasound interventional localization. In this case, the nodule was in the fat layer next to the superficial fascia. Her serum β-hCG level was decreased to 3.4 IU/L on the second postoperative day. The result of pathological examination was initially in line with CC metastasis to the abdominal wall, and the patient’s Ki-67 index was 20%. However, the patient’s pathological sections were sent to the Fudan University Obstetrics and Gynecology Hospital, another tertiary hospital in China, for further consultation, and the finding was ETT. Finally, the patient was encouraged to maintain close follow-up, and her serum β-hCG level had gradually decreased.\nIn the follow-up visits, the patient’s serum β-hCG level was elevated to the highest level of 10.68 IU/L again 4 months later , but she was still without any abdominal pain or abnormal vaginal bleeding. Furthermore, a pelvic CT scan showed several nodules on the abdominal wall midline fascia; the largest nodule was approximately 21 × 15 mm in size. The nodules had clear boundaries but were less uniform in internal echoes . Throughout the disease process, test results for tumor markers such as CA 125, CA 19-9, CEA, and HE4 were negative, and the results of routine blood sampling tests (blood cell count, liver and kidney function, coagulation function) were normal. We suggested a third resection of the mass to the patient, but she opted for a hysterectomy due to fear of malignancy and further relapse. She finally underwent exploratory laparotomy with removal of the abdominal wall lesion, subtotal hysterectomy, bilateral salpingectomy, and left ovarian cyst resection as well as right inguinal lymph node biopsy in July 2017. Intraoperative exploration revealed that the abdominal wall lesion was located on the anterior wall fascia.\nHistopathological observations suggested that hyperplasia of fatty fibrous tissue was visible with cancer infiltration and necrosis around the cancer tissue, which was consistent with trophoblastic tumor, constituted primarily by major epidermoid trophoblastic tumors (approximately 90%) and the remainder by CC components (approximately 10%) on the abdominal wall lesion . Immunohistochemistry showed β-hCG (focal positive), inhibin-α (epithelial trophoblast negative, CC positive), and p63 (epidermoid trophoblast positive, CC positive) . There was no tumor involvement in other tissues, including uterine, left ovarian cyst, and the right inguinal lymph nodes, which indicated an isolated and extrauterine mixed trophoblastic tumor. On the basis of all these findings, the diagnosis was ETT accompanying CC. The patient’s postoperative recovery was uneventful. Two weeks after hysterectomy, her serum β-hCG level had returned to normal (low 1.2 IU/L). Two years later, there was no evidence of recurrence according to serum β-hCG and imaging studies.", + "fulltext_subclaims": [ + "The patient was a 39-year-old Chinese woman.", + "She had delivered a second live full-term infant through an uncomplicated cesarean section in 2011.", + "She had a miscarriage in 2010.", + "She had a first cesarean section in 2005.", + "In December 2014, she noticed a purple, nontender swelling appearing as an anterior abdominal wall mass around her cesarean scar.", + "The mass was the size of a green bean.", + "The mass was not accompanied by any abdominal pain.", + "The mass was not accompanied by any abnormal vaginal bleeding.", + "There were no notable findings in her past medical history.", + "There were no notable findings in her family history.", + "There were no notable findings in her psychosocial history.", + "The abdominal wall mass had progressively enlarged.", + "She had undergone tumor resection of the abdominal wall in June 2015.", + "The resection might be interpreted as the abdominal wall endometriosis malignancy.", + "She had visited a regional tertiary hospital for a consultation regarding the pathologic diagnosis of a CC.", + "Her physical examination showed no abnormalities except for the scar from the local excision on the abdominal wall.", + "The first excised specimen from the previous hospital was reviewed by our pathologists.", + "The pathologists confirmed the characteristic of CC coexisting with minor ETT.", + "Her Ki-67 proliferative index was approximately 50%.", + "Laboratory analysis revealed normal serum levels of β-human chorionic gonadotropin (β-hCG; < 1.2 IU/L).", + "Laboratory analysis revealed normal tumor markers, including CA 125, CEA, CA 19-9, CA 15-3, and α-fetoprotein.", + "Positron emission tomography was performed.", + "No residual tumor and suspicious malignant lesions were observed.", + "Endometrial curettage was performed.", + "The results of endometrial curettage revealed normal menstrual phase endometrium.", + "The patient received two courses of chemotherapy with a regimen of etoposide and cisplatin (EP) over a 2-month period.", + "During chemotherapy, her serum β-hCG levels remained negative (< 1.2 IU/L).", + "A recurrent nodule was found on the same abdominal wall scar site in January 2017.", + "The nodule was found approximately 17 months after the last chemotherapy.", + "Her serum β-hCG had increased to 6.17 IU/L.", + "Two oval hypoechoic masses were visualized by ultrasonography in the subcutaneous soft tissue of the lower abdomen wall scar.", + "Chest CT and head MRI showed no abnormality.", + "She underwent a second notable mass excision by ultrasound interventional localization.", + "The nodule was in the fat layer next to the superficial fascia.", + "Her serum β-hCG level was decreased to 3.4 IU/L on the second postoperative day.", + "The result of pathological examination was initially in line with CC metastasis to the abdominal wall.", + "The patient’s Ki-67 index was 20%.", + "The patient’s pathological sections were sent to the Fudan University Obstetrics and Gynecology Hospital for further consultation.", + "The finding was ETT.", + "The patient was encouraged to maintain close follow-up.", + "Her serum β-hCG level had gradually decreased.", + "In the follow-up visits, the patient’s serum β-hCG level was elevated to the highest level of 10.68 IU/L again 4 months later.", + "A pelvic CT scan showed several nodules on the abdominal wall midline fascia.", + "The largest nodule was approximately 21 × 15 mm in size.", + "The nodules had clear boundaries.", + "The nodules were less uniform in internal echoes.", + "Test results for tumor markers such as CA 125, CA 19-9, CEA, and HE4 were negative.", + "The results of routine blood sampling tests were normal.", + "We suggested a third resection of the mass to the patient.", + "She opted for a hysterectomy due to fear of malignancy and further relapse.", + "She finally underwent exploratory laparotomy with removal of the abdominal wall lesion, subtotal hysterectomy, bilateral salpingectomy, left ovarian cyst resection, and right inguinal lymph node biopsy in July 2017.", + "Intraoperative exploration revealed that the abdominal wall lesion was located on the anterior wall fascia.", + "Histopathological observations suggested that hyperplasia of fatty fibrous tissue was visible with cancer infiltration and necrosis around the cancer tissue.", + "The histopathological findings were consistent with trophoblastic tumor.", + "The trophoblastic tumor was constituted primarily by major epidermoid trophoblastic tumors (approximately 90%).", + "The trophoblastic tumor was constituted by CC components (approximately 10%).", + "Immunohistochemistry showed β-hCG (focal positive).", + "Immunohistochemistry showed inhibin-α (epithelial trophoblast negative, CC positive).", + "Immunohistochemistry showed p63 (epidermoid trophoblast positive, CC positive).", + "There was no tumor involvement in other tissues, including uterine, left ovarian cyst, and the right inguinal lymph nodes.", + "The diagnosis was ETT accompanying CC.", + "The patient’s postoperative recovery was uneventful.", + "Two weeks after hysterectomy, her serum β-hCG level had returned to normal (low 1.2 IU/L).", + "Two years later, there was no evidence of recurrence according to serum β-hCG and imaging studies." + ], + "summary": "Our patient was a 39-year-old Chinese woman who had a history of two cesarean sections and one miscarriage. She had a recurrent anterior abdominal wall mass around her cesarean scar, and the mass was initially suspected of being choriocarcinoma of unknown origin. The patient had concomitant negative or mildly increased serum β-human chorionic gonadotropin at follow-up and no abnormal vaginal bleeding or abdominal pain. However, she underwent local excision twice and had two courses of chemotherapy with an etoposide and cisplatin regimen. She finally opted for exploratory laparotomy with abdominal wall lesion removal, subtotal hysterectomy, bilateral salpingectomy, and left ovarian cyst resection, which showed the abdominal wall lesion, whose components were revealed by microscopy and immunohistochemical staining to be approximately 90% epithelioid trophoblastic tumors and 10% choriocarcinomas from a solely extrauterine mixed gestational trophoblastic neoplasm around an abdominal wall cesarean scar.", + "summary_subclaims": [ + "The patient was a 39-year-old Chinese woman.", + "She had a history of two cesarean sections.", + "She had a history of one miscarriage.", + "She had a recurrent anterior abdominal wall mass around her cesarean scar.", + "The mass was initially suspected of being choriocarcinoma of unknown origin.", + "The patient had negative or mildly increased serum β-human chorionic gonadotropin at follow-up.", + "She had no abnormal vaginal bleeding.", + "She had no abdominal pain.", + "She underwent local excision twice.", + "She had two courses of chemotherapy with an etoposide and cisplatin regimen.", + "She finally opted for exploratory laparotomy with abdominal wall lesion removal.", + "She had a subtotal hysterectomy.", + "She had bilateral salpingectomy.", + "She had left ovarian cyst resection.", + "The abdominal wall lesion was revealed by microscopy and immunohistochemical staining to be approximately 90% epithelioid trophoblastic tumors.", + "The abdominal wall lesion was revealed by microscopy and immunohistochemical staining to be 10% choriocarcinomas.", + "The lesion was from a solely extrauterine mixed gestational trophoblastic neoplasm around an abdominal wall cesarean scar." + ] + }, + { + "id": "multiclinsum_test_2345_en.txt", + "fulltext": "A 75 year old Jamaican Female of African descent was admitted for shortness of breath. She had been complaining of fatigue and shortness of breath for six months since arriving in the U.S. from Jamaica. She reported mild symptoms in Jamaica, but felt they had worsened during her time in the States. She had been admitted multiple times to at least four different hospitals since her symptoms began. She had been treated for both congestive heart failure (CHF) and asthma exacerbations, despite carrying no significant history of either condition. At the time of the admission described herein, she had been discharged from another hospital two days prior on a tapered prednisone regimen prescribed for an \"asthma exacerbation\".\nA review of systems at the time of admission revealed symptoms consistent with New York Heart Association Class IV CHF, including orthopnea, paroxysmal nocturnal dyspnea, lower extremity edema, and a virtually non-existent exercise tolerance.\nOn examination the patient was in acute distress, sitting bolt upright in bed and tripodding. She was obese. Jugular venous distension was difficult to discern due to her body habitus. She did not have a palpable point of maximal impulse. Her heart sounds were distant but regular with a II/VI systolic ejection murmur heard loudest over the right upper sternal border which did not radiate. Her breath sounds were absent at the bases and diminished 2/3 of the way up the posterior lung fields. She had 2+ pitting edema to the hips. There was no hepatomegaly or macroglossia.\nHer electrocardiogram (ECG) at the time of admission showed diffuse low voltage and Q waves in leads III and aVf . A trans-thoracic echocardiogram (TTE) was performed soon after admission . It showed moderately reduced left ventricular function with an ejection fraction (EF) of 33%, a small left ventricular cavity (20.4 cm2 in diastole, 16.3 cm2 in systole), markedly increased wall thickness (septal diameter in diastole = 1.86 cm), and severe concentric hypertrophy. Additionally, there was moderate mitral regurgitation. A speckled pattern in the myocardium was noted.\nBoth serum and urine protein electrophoresis demonstrated a normal protein distribution without a monoclonal spike. She had modestly impaired renal function (estimated GFR 51 mL/min by Cockocroft-Gault, 52 mL/min by Modification of Diet in Renal Disease Criteria) with no proteinuria.\nShe was diuresed using furosemide, and treated with monopril, metoprolol (later changed to carvedilol for better blood pressure control), and digoxin. There was little subjective or objective improvement in her condition with this treatment. The digoxin was stopped on the 5th hospital day, as the suspicion for Amyloidosis at that point in time was high.\nShe underwent a fat pad aspiration biopsy, which was negative for amyloid by Congo Red Staining. At that time, it was felt that her refractory condition, in combination with the ECG and TTE data was sufficiently suggestive of amyloid disease that she should undergo endomyocardial biopsy as a means of definitive diagnosis. The biopsy revealed AL Amyloidosis with kappa and lambda light chain deposits. Stains for iron and amyloid AA were negative.", + "fulltext_subclaims": [ + "The patient is a 75 year old Jamaican Female of African descent.", + "She was admitted for shortness of breath.", + "She had been complaining of fatigue and shortness of breath for six months.", + "She had been admitted multiple times to at least four different hospitals since her symptoms began.", + "She had been treated for both congestive heart failure and asthma exacerbations.", + "She had been discharged from another hospital two days prior on a tapered prednisone regimen prescribed for an \"asthma exacerbation\".", + "A review of systems at the time of admission revealed symptoms consistent with New York Heart Association Class IV CHF.", + "On examination, the patient was in acute distress, sitting bolt upright in bed and tripodding.", + "She was obese.", + "Jugular venous distension was difficult to discern due to her body habitus.", + "Her heart sounds were distant but regular with a II/VI systolic ejection murmur heard loudest over the right upper sternal border.", + "Her breath sounds were absent at the bases and diminished 2/3 of the way up the posterior lung fields.", + "She had 2+ pitting edema to the hips.", + "Her electrocardiogram showed diffuse low voltage and Q waves in leads III and aVf.", + "A trans-thoracic echocardiogram showed moderately reduced left ventricular function with an ejection fraction of 33%.", + "The echocardiogram showed a small left ventricular cavity.", + "The echocardiogram showed markedly increased wall thickness.", + "The echocardiogram showed severe concentric hypertrophy.", + "The echocardiogram showed moderate mitral regurgitation.", + "A speckled pattern in the myocardium was noted.", + "Both serum and urine protein electrophoresis demonstrated a normal protein distribution without a monoclonal spike.", + "She had modestly impaired renal function.", + "She was diuresed using furosemide.", + "She was treated with monopril, metoprolol, and digoxin.", + "There was little subjective or objective improvement in her condition with this treatment.", + "The digoxin was stopped on the 5th hospital day.", + "A fat pad aspiration biopsy was negative for amyloid by Congo Red Staining.", + "She underwent endomyocardial biopsy.", + "The biopsy revealed AL Amyloidosis with kappa and lambda light chain deposits.", + "Stains for iron and amyloid AA were negative." + ], + "summary": "Herein a case of Familial Amyloidosis initially mistaken for the AL form based on a false positive laboratory result is presented. This case illustrates the high index of suspicion required for proper diagnosis of this rare disease.", + "summary_subclaims": [ + "A case of Familial Amyloidosis initially mistaken for the AL form based on a false positive laboratory result is presented.", + "This case illustrates the high index of suspicion required for proper diagnosis of this rare disease." + ] + }, + { + "id": "multiclinsum_test_2119_en.txt", + "fulltext": "A 4-year-old boy with history of an accidental ingestion of a metallic nail presented to the emergency department few hours after the ingestion and the examination was normal at that time, the plain abdominal X-ray confirmed the presence nail in the abdomen. The parents were reassured about the possibility of the spontaneous passage of the nail with the stool and they have been advised to visit the hospital if the child develops any kind of symptom. One week later he presented with right iliac fossa pain and one attack of vomiting.\nDuring abdominal examination, the abdomen was not distended and soft, there was tenderness and rebound tenderness at the right iliac fossa, the bowel sounds were normal and no palpable mass detected.\nPlain abdominal X-ray of the abdomen showed the metallic nail in the region of the right iliac fossa, with no other abnormal finding, . Ultrasound examination of the abdomen showed no fluid collection and there was tenderness on putting the probe on the region of the right lilac fossa.\nThe white blood cell count was elevated (14,000 cells per microliter).\nBefore surgery we suspected impaction at the ileocecal junction and if surgery is delayed it may lead to bowel perforation. During surgery surprisingly the nail was impacted the lumen of the vermiform appendix causing inflammation , .\nAppendicectomy done and the patient admitted for two days with no postoperative complications.\nThe patient discharged on the third day in a good general condition.", + "fulltext_subclaims": [ + "A 4-year-old boy with history of an accidental ingestion of a metallic nail presented to the emergency department few hours after the ingestion.", + "The examination was normal at that time.", + "The plain abdominal X-ray confirmed the presence of the nail in the abdomen.", + "The parents were reassured about the possibility of the spontaneous passage of the nail with the stool.", + "The parents have been advised to visit the hospital if the child develops any kind of symptom.", + "One week later he presented with right iliac fossa pain and one attack of vomiting.", + "During abdominal examination, the abdomen was not distended and soft.", + "There was tenderness and rebound tenderness at the right iliac fossa.", + "The bowel sounds were normal.", + "No palpable mass was detected.", + "Plain abdominal X-ray of the abdomen showed the metallic nail in the region of the right iliac fossa.", + "The white blood cell count was elevated (14,000 cells per microliter).", + "Before surgery we suspected impaction at the ileocecal junction.", + "If surgery is delayed it may lead to bowel perforation.", + "During surgery the nail was impacted in the lumen of the vermiform appendix causing inflammation.", + "Appendicectomy was done.", + "The patient was admitted for two days with no postoperative complications.", + "The patient was discharged on the third day in a good general condition." + ], + "summary": "A 4-year-old boy with history of an accidental ingestion of a metallic nail presented to the emergency department one week later with right iliac fossa pain and one attack of vomiting. During abdominal examination there was tenderness and rebound tenderness at the right iliac fossa. Plain abdominal X-ray showed the metallic nail in the region of the right iliac fossa. Ultrasound examination was normal apart from tenderness of putting the probe on the right lilac fossa. The white blood cell counts were 14,000 cell per microliter. During surgery the nail was found to be impacted inside the lumen of the vermiform appendix causing inflammation of the appendix. Appendicectomy done and the patient discharged on the third day in a good general condition.", + "summary_subclaims": [ + "A 4-year-old boy with history of an accidental ingestion of a metallic nail presented to the emergency department one week later with right iliac fossa pain and one attack of vomiting.", + "During abdominal examination there was tenderness and rebound tenderness at the right iliac fossa.", + "Plain abdominal X-ray showed the metallic nail in the region of the right iliac fossa.", + "Ultrasound examination was normal apart from tenderness of putting the probe on the right lilac fossa.", + "The white blood cell counts were 14,000 cell per microliter.", + "During surgery the nail was found to be impacted inside the lumen of the vermiform appendix causing inflammation of the appendix.", + "Appendicectomy done and the patient discharged on the third day in a good general condition." + ] + }, + { + "id": "multiclinsum_test_1472_en.txt", + "fulltext": "A 53-year-old Chinese woman had health checkups, including gastroscopy examinations, and then was hospitalized in our hospital following the finding of a submucosal lesion in upper endoscopy. She had no complaint of dysphagia, odynophagia, abdominal pain, poor appetite or weight loss.\nGastroscopy performed in another hospital showed a submucosal protruding mass in the esophagus 25 cm from the incisors, and a diagnosis of external pressure esophageal apophysis was considered.\nThe patient had a history of hypertension for more than 2 years, and was treated daily with oral antihypertensive drugs in the form of 2.5 mg levamlodipine dispersible tablets.\nThe patient’s family history and past medical history were both unremarkable. She had no history of esophagitis or esophageal tuberculosis.\nThe patient’s temperature was 36.8°C, heart rate was 80 bpm, respiratory rate was 19 breaths/min and blood pressure was 125/80 mmHg. The breath sounds of both lungs were clear, no dry and wet rales were heard, the abdomen was soft, with no tenderness, no rebound pain and no palpable mass.\nDuring hospitalization, routine laboratory parameters were within the normal range. Tumor markers including carcinoembryonic antigen and cancer antigen 125 were negative.\nIn order to help reveal the nature of a cyst, enhanced thoracic computed tomography (CT) was done, and it revealed an ovular low-density shadow with a clear boundary of about 3.6 cm × 1.8 cm in the upper middle part of the esophagus, with mild to moderate enhancement. There was no obvious thickening of the esophageal wall, no obvious dilatation or obstruction of the esophagus, and no obvious enlarged lymph nodes in the mediastinum . Thus, a diagnosis of esophageal leiomyoma was considered.\nUpon upper gastrointestinal endoscopy, a submucosal mass was observed about 28 cm from the incisor with a gourd-like appearance, and the size was about 4.0 cm × 2.0 cm .\nEUS with a 12-MHz radial probe revealed a hypoechoic irregular mass arising within the propria muscularis in the middle segment of the esophagus (28 cm from the incisor), with a clear boundary, cystic wall, uneven echo, spot-like echo, and a separation zone inside. The measured area was 3.2 cm × 2.0 cm. Contrast-enhanced US showed enhancement around the lesion but no internal enhancement .", + "fulltext_subclaims": [ + "The patient is a 53-year-old Chinese woman.", + "She had health checkups, including gastroscopy examinations.", + "She was hospitalized following the finding of a submucosal lesion in upper endoscopy.", + "She had no complaint of dysphagia.", + "She had no complaint of odynophagia.", + "She had no complaint of abdominal pain.", + "She had no complaint of poor appetite.", + "She had no complaint of weight loss.", + "Gastroscopy performed in another hospital showed a submucosal protruding mass in the esophagus 25 cm from the incisors.", + "A diagnosis of external pressure esophageal apophysis was considered.", + "The patient had a history of hypertension for more than 2 years.", + "She was treated daily with oral antihypertensive drugs in the form of 2.5 mg levamlodipine dispersible tablets.", + "The patient’s family history was unremarkable.", + "The patient’s past medical history was unremarkable.", + "She had no history of esophagitis.", + "She had no history of esophageal tuberculosis.", + "The patient’s temperature was 36.8°C.", + "The patient’s heart rate was 80 bpm.", + "The patient’s blood pressure was 125/80 mmHg.", + "The breath sounds of both lungs were clear.", + "No dry and wet rales were heard.", + "The abdomen was soft.", + "There was no tenderness.", + "There was no rebound pain.", + "There was no palpable mass.", + "Routine laboratory parameters were within the normal range.", + "Tumor markers including carcinoembryonic antigen and cancer antigen 125 were negative.", + "Enhanced thoracic computed tomography (CT) revealed an ovular low-density shadow with a clear boundary of about 3.6 cm × 1.8 cm in the upper middle part of the esophagus.", + "There was no obvious thickening of the esophageal wall.", + "There was no obvious dilatation or obstruction of the esophagus.", + "There were no obvious enlarged lymph nodes in the mediastinum.", + "A diagnosis of esophageal leiomyoma was considered.", + "Upon upper gastrointestinal endoscopy, a submucosal mass was observed about 28 cm from the incisor.", + "The submucosal mass had a gourd-like appearance.", + "The submucosal mass was about 4.0 cm × 2.0 cm.", + "EUS with a 12-MHz radial probe revealed a hypoechoic irregular mass arising within the propria muscularis in the middle segment of the esophagus.", + "The mass was 28 cm from the incisor.", + "The mass had a clear boundary.", + "The mass had a cystic wall.", + "The mass had uneven echo.", + "The mass had spot-like echo.", + "There was a separation zone inside the mass.", + "The measured area of the mass was 3.2 cm × 2.0 cm.", + "Contrast-enhanced US showed enhancement around the lesion.", + "There was no internal enhancement." + ], + "summary": "We report a 53-year-old Chinese woman hospitalized in our hospital following the discovery of a submucosal protruding mass of the esophagus by upper endoscopy. A preliminary diagnosis of EBC was made by endoscopic ultrasonography (EUS), and treatment was accomplished by endoscopic submucosal tunnel dissection (ESTD). The pathological results verified the diagnosis. No scar changes or cystic lesion within the original lesion were found under EUS after a 3-mo follow-up.", + "summary_subclaims": [ + "The patient is a 53-year-old Chinese woman.", + "The patient was hospitalized following the discovery of a submucosal protruding mass of the esophagus by upper endoscopy.", + "A preliminary diagnosis of EBC was made by endoscopic ultrasonography.", + "Treatment was accomplished by endoscopic submucosal tunnel dissection.", + "The pathological results verified the diagnosis.", + "No scar changes or cystic lesion within the original lesion were found under EUS after a 3-mo follow-up." + ] + }, + { + "id": "multiclinsum_test_3008_en.txt", + "fulltext": "A 37-year-old male patient presented to a surgical emergency with the complaint of blackish skin discoloration of the Right arm over the region of the deltoid with severe pain. He had a history of intramuscular diclofenac 75 mg injection into the right deltoid one day back for generalized musculoskeletal pains. The swelling progressed rapidly throughout 24 to 30 h. Past medical and surgical history was unremarkable. There was no history of intake of steroids or any other drug that could lead to an immunocompromised state. No history of illicit drug use. On general physical examination, the patient was anxious, irritable, pale, dehydrated, febrile, and was having a toxic look. He was tachycardic with a pulse rate of 106 beats per minute, respiratory rate was 24 cycles per minute and he was also found to be hypotensive with systolic blood pressure of 90 mmHg.\nLocal examination revealed a swollen right arm with blackish discoloration over the region of the right deltoid. On palpation, the whole of the right arm was extremely tender, and tense, and had extended subcutaneous emphysema. Furthermore, pallor, pulselessness, and paresthesia of the distal limb raised strong clinical suspicion of compartment syndrome. Establishing a preliminary diagnosis of gas gangrene with concomitant compartment syndrome, immediate resuscitation was given with intravenous fluids, broad-spectrum antibiotics, and strong analgesia. Vital monitoring and IOP started. Arterial blood gas analysis was performed which revealed metabolic acidosis with respiratory compensation. On blood tests, leucocyte count was 18,500 per microliter and C-reactive protein was 53 mg/dl. His creatinine was 1.7 mg/dl and urea was 95 mg/dl. Total bilirubin was 2.7 mg/dl, ALT was 160 units/l. The patient received prompt treatment with release incisions, surgical debridement, and resection of necrotic tissue. All the open wounds were copiously washed with hydrogen peroxide and normal saline. Wounds were covered with antibiotic dressings. Cultures of the fluid from necrotic tissue resulted in a positive for Staphylococcus epidermidis, clostridium perfringens, and Staphylococcus aureus. Histologic examination of the tissue removed from the right deltoid and triceps region described colliquative necrosis. After debridement, the patient was shifted to the ward and monitored for 24 h. On the next day margins of the wounds became increasingly necrosed, and the gangrene extended to anterior and posterior chest walls beyond anterior and posterior axillary lines. Re-Debridement was planned, wound margins were refreshed and the whole of the necrotic muscles involving the triceps and part of the latissimus dorsi were debrided. According to the results of culture sensitivity meropenem, 1 g 12 hourly was administrated. Minor serial detriments were performed over the subsequent days and the wounds were managed with regular dressings. The patient remained under close observation receiving intensive supportive care for almost 4 weeks. Gradual improvement was noted with the development of healthy granulation tissue. The patient was discharged in stable condition with continued outpatient wound care and follow-up in the department of plastic surgery for possible skin grafting after the establishment of healthy granulation tissue.", + "fulltext_subclaims": [ + "The patient is a 37-year-old male.", + "The patient presented with blackish skin discoloration of the right arm over the region of the deltoid.", + "The patient had a history of intramuscular diclofenac 75 mg injection into the right deltoid one day before presentation.", + "The swelling progressed rapidly throughout 24 to 30 hours.", + "The patient had no history of intake of steroids.", + "The patient had no history of illicit drug use.", + "On general physical examination, the patient was febrile.", + "On general physical examination, the patient was hypotensive with a systolic blood pressure of 90 mmHg.", + "Local examination revealed subcutaneous emphysema.", + "Pallor, pulselessness, and paresthesia of the distal limb raised strong clinical suspicion of compartment syndrome.", + "A preliminary diagnosis of gas gangrene with concomitant compartment syndrome was established.", + "Intravenous fluids were given.", + "Broad-spectrum antibiotics were given.", + "Arterial blood gas analysis revealed metabolic acidosis with respiratory compensation.", + "The leucocyte count was 18,500 per microliter.", + "The C-reactive protein was 53 mg/dl.", + "The creatinine was 1.7 mg/dl.", + "The urea was 95 mg/dl.", + "The total bilirubin was 2.7 mg/dl.", + "The ALT was 160 units/l.", + "The patient received release incisions.", + "The patient received surgical debridement.", + "The patient received resection of necrotic tissue.", + "The open wounds were washed with hydrogen peroxide and normal saline.", + "Cultures of the fluid from necrotic tissue were positive for Staphylococcus epidermidis.", + "Cultures of the fluid from necrotic tissue were positive for Clostridium perfringens.", + "Cultures of the fluid from necrotic tissue were positive for Staphylococcus aureus.", + "Histologic examination of the tissue described colliquative necrosis.", + "The patient was shifted to the ward after debridement.", + "The patient was monitored for 24 hours.", + "On the next day, the margins of the wounds became increasingly necrosed.", + "The gangrene extended to the anterior and posterior chest walls beyond the anterior and posterior axillary lines.", + "Re-debridement was planned.", + "The wound margins were refreshed.", + "The whole of the necrotic muscles involving the triceps and part of the latissimus dorsi were debrided.", + "Meropenem, 1 g 12 hourly, was administered.", + "Minor serial debridements were performed over the subsequent days.", + "The wounds were managed with regular dressings.", + "The patient remained under close observation receiving intensive supportive care for almost 4 weeks.", + "Gradual improvement was noted with the development of healthy granulation tissue.", + "The patient was discharged in stable condition.", + "The patient was advised continued outpatient wound care.", + "The patient was advised follow-up in the department of plastic surgery for possible skin grafting after the establishment of healthy granulation tissue." + ], + "summary": "A 37-year-old male developed severe pain, blackish skin discoloration, and rapidly progressing swelling of the right deltoid after receiving an intramuscular diclofenac injection. Within 24-30 h, he exhibited sepsis and compartment syndrome. Emergency fasciotomy and surgical debridement were performed, and cultures confirmed a polymicrobial infection, including Clostridium perfringens. He was treated with broad-spectrum antibiotics, intensive care, and serial debridement, leading to a gradual recovery. After three weeks of hospitalization, he was discharged in stable condition with follow-up for wound care and skin grafting.", + "summary_subclaims": [ + "The patient was a 37-year-old male.", + "He developed severe pain after receiving an intramuscular diclofenac injection.", + "He had blackish skin discoloration of the right deltoid.", + "He had rapidly progressing swelling of the right deltoid.", + "Within 24-30 h, he exhibited sepsis.", + "Within 24-30 h, he exhibited compartment syndrome.", + "Emergency fasciotomy was performed.", + "Surgical debridement was performed.", + "Cultures confirmed a polymicrobial infection.", + "The infection included Clostridium perfringens.", + "He was treated with broad-spectrum antibiotics.", + "He received intensive care.", + "He had serial debridement.", + "He had a gradual recovery.", + "He was discharged after three weeks of hospitalization.", + "He was discharged in stable condition.", + "He had follow-up for wound care.", + "He had follow-up for skin grafting." + ] + }, + { + "id": "multiclinsum_test_2974_en.txt", + "fulltext": "Multiple joint swelling for 10 years, which was aggravated for 1 year.\nThe patient was a 67-year-old woman who experienced bilateral knee swelling and pain 10 years ago without apparent cause and was diagnosed with rheumatoid arthritis at a local hospital. She treated herself with over-the-counter oral anti-rheumatic drugs. In the past year, the joint swelling and pain gradually worsened and affected the entire body, mainly involving the bilateral joints of the hands, knees, wrists, and shoulders. The swelling and pain were slightly more serious on bilateral shoulder joints and right knee. In addition, the patient had dry eyes and mouth and should drink water when eating dried food. She was then presented to Division of Rheumatology and Immunology. According to laboratory testing results, she was diagnosed with rheumatoid arthritis. Computed tomography (CT) revealed an anterior mediastinal tumor. She was subsequently transferred to the Department of Thoracic Surgery for surgical treatment.\nTen years of hypertension, without any medical treatment; systolic blood pressure 150 -160 mmHg, and diastolic blood pressure 95-105 mmHg.\nThere was no remarkable family history of related diseases.\nMultiple joint swelling.\nLaboratory testing results were as follows: SS-A, weakly positive; erythrocyte sedimentation rate, 39 mm/h; antinuclear antibody, 1:320 (+); immunoglobulin G, 17.10 g/L; immunoglobulin M, 2.58 g/L; C-reactive protein, 11.10 mg/L; and rheumatoid factor, 941 IU/mL.\nChest CT showed a shadow of dense fat visible in the anterior mediastinum. Multiple fat-dense nodules of varying sizes were observed, with a maximum diameter of 44 mm × 28 mm. Calcification was observed around some nodules. No enhancement was seen on enhanced CT .\nThe border of the tumor and tissue was well-defined. The cut surface was grayish white or grayish yellow. The tumor had a soft to firm texture depending on the fat contents. Microscopically, the tumor cells were highly pleomorphic. Mature adipocyte areas admixed with spindle cells were observed. Some nuclei were mildly atypical. Floret-like giant cells were observed, and focal calcification was present. Thick-walled blood vessels were visible. Spindle cells with mild nuclear atypia and hyperchromatic nuclei were observed. The results of immunohistochemical analysis were CD117 (-), Dog-1 (-), S-100 (partial +), SMA (partial +), CK (-), desmin (-), vimentin (+), Ki67 (5%), CD34 (+), and CD68 (-) .", + "fulltext_subclaims": [ + "The patient was a 67-year-old woman.", + "She experienced bilateral knee swelling and pain 10 years ago without apparent cause.", + "She was diagnosed with rheumatoid arthritis at a local hospital.", + "She treated herself with over-the-counter oral anti-rheumatic drugs.", + "In the past year, the joint swelling and pain gradually worsened and affected the entire body.", + "The swelling and pain mainly involved the bilateral joints of the hands, knees, wrists, and shoulders.", + "The swelling and pain were slightly more serious on bilateral shoulder joints and right knee.", + "She had dry eyes and mouth.", + "She should drink water when eating dried food.", + "She was presented to the Division of Rheumatology and Immunology.", + "According to laboratory testing results, she was diagnosed with rheumatoid arthritis.", + "Computed tomography (CT) revealed an anterior mediastinal tumor.", + "She was subsequently transferred to the Department of Thoracic Surgery for surgical treatment.", + "She had ten years of hypertension.", + "She did not receive any medical treatment for hypertension.", + "Her systolic blood pressure was 150 -160 mmHg.", + "Her diastolic blood pressure was 95-105 mmHg.", + "There was no remarkable family history of related diseases.", + "Multiple joint swelling was reported.", + "SS-A was weakly positive.", + "Erythrocyte sedimentation rate was 39 mm/h.", + "Antinuclear antibody was 1:320 (+).", + "Immunoglobulin G was 17.10 g/L.", + "Immunoglobulin M was 2.58 g/L.", + "C-reactive protein was 11.10 mg/L.", + "Rheumatoid factor was 941 IU/mL.", + "Chest CT showed a shadow of dense fat visible in the anterior mediastinum.", + "Multiple fat-dense nodules of varying sizes were observed.", + "The maximum diameter of the nodules was 44 mm × 28 mm.", + "Calcification was observed around some nodules.", + "No enhancement was seen on enhanced CT.", + "The border of the tumor and tissue was well-defined.", + "The cut surface was grayish white or grayish yellow.", + "The tumor had a soft to firm texture depending on the fat contents.", + "Microscopically, the tumor cells were highly pleomorphic.", + "Mature adipocyte areas admixed with spindle cells were observed.", + "Some nuclei were mildly atypical.", + "Floret-like giant cells were observed.", + "Focal calcification was present.", + "Thick-walled blood vessels were visible.", + "Spindle cells with mild nuclear atypia and hyperchromatic nuclei were observed.", + "The results of immunohistochemical analysis were CD117 (-).", + "The results of immunohistochemical analysis were Dog-1 (-).", + "The results of immunohistochemical analysis were S-100 (partial +).", + "The results of immunohistochemical analysis were SMA (partial +).", + "The results of immunohistochemical analysis were CK (-).", + "The results of immunohistochemical analysis were desmin (-).", + "The results of immunohistochemical analysis were vimentin (+).", + "The results of immunohistochemical analysis were Ki67 (5%).", + "The results of immunohistochemical analysis were CD34 (+).", + "The results of immunohistochemical analysis were CD68 (-)." + ], + "summary": "Herein, we report the case of a 67-year-old woman diagnosed with PL in the anterior mediastinum. The tumor was removed by thoracoscopic surgery. There was no recurrence during the 24-mo follow-up period, and the prognosis was good. Most PL are located on the skin surface. However, they may also occur within the body, even in the mediastinum.", + "summary_subclaims": [ + "The patient was a 67-year-old woman.", + "The patient was diagnosed with PL in the anterior mediastinum.", + "The tumor was removed by thoracoscopic surgery.", + "There was no recurrence during the 24-mo follow-up period.", + "The prognosis was good.", + "Most PL are located on the skin surface.", + "PL may also occur within the body.", + "PL may also occur in the mediastinum." + ] + }, + { + "id": "multiclinsum_test_2559_en.txt", + "fulltext": "A 66-year-old male with a history of type 2 diabetes mellitus and osteoarthritis, on no prescribed medications, presented with haemoptysis and chest pain. On examination, the temperature was 36.7°C, the blood pressure 84/69 mmHg, the heart rate 130 b.p.m., the respiratory rate 18 breaths per minute, and the oxygen saturation 100% on room air. Cardiopulmonary exam was overall unremarkable. A mass was noted in the right deltoid muscle region.\nThe ECG at presentation showed sinus tachycardia with a heart rate of 117 b.p.m. and marked convex STE in multiple leads including V2–V6, I, and aVL, with reciprocal changes . ST-elevation myocardial infarction code was activated. Emergent coronary angiography showed no significant coronary obstruction . The STE was persistent on subsequent ECGs and blood cardiac troponin I (cTnI) levels were within normal range (<0.3 ng/mL). The complete blood count and basic metabolic panel were unremarkable except for mild hyponatraemia with sodium level of 130 mEq/L (normal sodium level 135–145 mEq/L) and mildly elevated fasting plasma glucose level of 7.1 mmol/L. The chest X-ray showed a right upper lobe wedge-shaped airspace consolidation.\nThe transthoracic echocardiogram (TTE) showed severe focal wall thickening and hypokinesis/akinesis in apical, apical lateral, anteroseptal, and anterior wall. The thickened wall is characterized by heterogenous echogenicity different from that of normal myocardium. Mural mobile echodensities associated with the hypokinetic/akinetic wall were seen in the left ventricle, consistent with mural thrombi . Computed tomography (CT) of the chest showed a large partially cavitated lung mass within the right upper lobe. Given the haemoptysis and cavitated lung mass, thus bleeding concern, anticoagulation was held. Ultrasound-guided needle biopsy of the right deltoid muscle mass was performed, and the histological analysis showed infiltrating squamous cell carcinoma .\nIn further delineating the myocardial damage, cardiac magnetic resonance (CMR) was performed, which showed focal wall thickening with regional hypokinesis/akinesis due to infiltrative masses involving apical, apical lateral, anteroseptal, and anterior wall, consistent with malignant cardiac metastases . An 18F-fluorodeoxyglucose (FDG)-positron emission tomography (PET)-CT imaging showed large areas of hypermetabolic activity corresponding to the myocardial metastasis as shown on CMR imaging and a large hypermetabolic mass in the right upper lobe consistent with primary lung malignancy .\nThe patient was seen by oncology and diagnosed with stage IV lung squamous cell carcinoma. Palliative chemoimmunotherapy was started. The persistent STE was still present on the follow-up ECG obtained 2 months after clinical presentation and the patient remained clinically stable from a cardiac standpoint.", + "fulltext_subclaims": [ + "The patient is a 66-year-old male.", + "The patient has a history of type 2 diabetes mellitus.", + "The patient has a history of osteoarthritis.", + "The patient is on no prescribed medications.", + "The patient presented with haemoptysis.", + "The patient presented with chest pain.", + "The temperature was 36.7°C.", + "The blood pressure was 84/69 mmHg.", + "The heart rate was 130 b.p.m.", + "The oxygen saturation was 100% on room air.", + "A mass was noted in the right deltoid muscle region.", + "The ECG showed sinus tachycardia with a heart rate of 117 b.p.m.", + "The ECG showed marked convex STE in multiple leads including V2–V6, I, and aVL.", + "The ECG showed reciprocal changes.", + "ST-elevation myocardial infarction code was activated.", + "Emergent coronary angiography showed no significant coronary obstruction.", + "The STE was persistent on subsequent ECGs.", + "The blood cardiac troponin I (cTnI) levels were within normal range (<0.3 ng/mL).", + "The complete blood count was unremarkable.", + "The basic metabolic panel was unremarkable except for mild hyponatraemia with sodium level of 130 mEq/L.", + "The chest X-ray showed a right upper lobe wedge-shaped airspace consolidation.", + "The TTE showed severe focal wall thickening and hypokinesis/akinesis in apical, apical lateral, anteroseptal, and anterior wall.", + "The thickened wall is characterized by heterogenous echogenicity different from that of normal myocardium.", + "Mural mobile echodensities associated with the hypokinetic/akinetic wall were seen in the left ventricle.", + "The mural mobile echodensities were consistent with mural thrombi.", + "Computed tomography of the chest showed a large partially cavitated lung mass within the right upper lobe.", + "Anticoagulation was held due to the haemoptysis and cavitated lung mass.", + "Ultrasound-guided needle biopsy of the right deltoid muscle mass was performed.", + "The histological analysis showed infiltrating squamous cell carcinoma.", + "The CMR showed focal wall thickening with regional hypokinesis/akinesis due to infiltrative masses involving apical, apical lateral, anteroseptal, and anterior wall.", + "The CMR findings were consistent with malignant cardiac metastases.", + "The FDG-PET-CT imaging showed large areas of hypermetabolic activity corresponding to the myocardial metastasis.", + "The FDG-PET-CT imaging showed a large hypermetabolic mass in the right upper lobe consistent with primary lung malignancy.", + "The patient was diagnosed with stage IV lung squamous cell carcinoma.", + "Palliative chemoimmunotherapy was started.", + "The persistent STE was still present on the follow-up ECG obtained 2 months after clinical presentation.", + "The patient remained clinically stable from a cardiac standpoint." + ], + "summary": "We report a case of a 66-year-old man, with a history of diabetes mellitus and arthritis presenting with haemoptysis and chest pain. The electrocardiogram (ECG) at presentation showed marked localizing STE but emergent cardiac catheterization showed no significant coronary artery obstruction and the serial serum cardiac troponin levels were within normal limits. The patient was found to have squamous cell carcinoma with a right upper lobe cavitated lung mass and cardiac infiltrative metastasis as shown by computed tomography, echocardiography, cardiac magnetic resonance, and 18F-fluorodeoxyglucose-positron emission tomography-computed tomography (FDG-PET-CT) imaging. Mobile left ventricular mural thrombi were also noted on echocardiography.", + "summary_subclaims": [ + "The patient is a 66-year-old man.", + "The patient has a history of diabetes mellitus.", + "The patient has a history of arthritis.", + "The patient presented with haemoptysis.", + "The patient presented with chest pain.", + "The ECG at presentation showed marked localizing STE.", + "Emergent cardiac catheterization showed no significant coronary artery obstruction.", + "The serial serum cardiac troponin levels were within normal limits.", + "The patient was found to have squamous cell carcinoma.", + "The patient had a right upper lobe cavitated lung mass.", + "Cardiac infiltrative metastasis was shown by computed tomography.", + "Cardiac infiltrative metastasis was shown by echocardiography.", + "Cardiac infiltrative metastasis was shown by cardiac magnetic resonance.", + "Cardiac infiltrative metastasis was shown by FDG-PET-CT imaging.", + "Mobile left ventricular mural thrombi were noted on echocardiography." + ] + }, + { + "id": "multiclinsum_test_1433_en.txt", + "fulltext": "A 55-year-old female was admitted to the hospital’s emergency department with the chief complaint of a painful mass located in the right thigh and perineal area and with progressed pain and paresthesia to the right thigh and right shin. The patient seemed ill but not toxic. No history of fever, abdominal pain, digestive dysfunctions, chest pain, cough, hemoptysis, urticarial were found. The vital signs were in a normal range, and there was no family history.\nPhysical examination showed that the skin over the mass had no discoloration, and the size of the mass was around 5.7 cm long. The blood tests were normal, and the lab results showed no eosinophilia. The result of the ultrasonography examination was a cystic mass with suspicion toward femoral hernia. After a CT scan, the result of secondary workups was a multi-lobular cystic mass with no connection to the abdominal region , which suggested a hydatid cyst.\nThe patient underwent surgery under spinal anesthesia in the next step, and the right thigh was opened up. A cystic mass with ecto- and endocyst with clinical similarity to a hydatid cyst was removed with wide margins and without penetration of the cyst wall. The removed specimen was sent for histological examination with the first impression of cystic hydatidosis.\nReceived specimen in formalin consist of a creamy-whitish colored cyst M = 7 * 5 * 3 cm filled by multiple variable-sized creamy cysts . The cyst consists of three layers; the outermost fibrous pericyst layer, the middle laminated ectocyst layer, and the inner hyaline and acellular endocyst as the germinative layer, which encompasses daughter cysts and brood capsules with scolices. There may be granulomatous palisading reaction and pseudocyst formation as seen in cutaneous lesions .\nFollowing the surgical removal of the cyst, the patient underwent recovery. Besides, Post-surgical Abdominal and thoracic Ultrasonography screening were used to exclude recurrence. Albendazole 400 mg PO BID was prescribed for 3–6 months. An 18-months follow-up demonstrated no reoccurrence or any other site of cystic hydatidosis.\nAfter a year of routine follow-up, the patient did not demonstrate any signs of recurrence of the adverse effect of surgery, and she was entirely well.", + "fulltext_subclaims": [ + "The patient was a 55-year-old female.", + "The patient was admitted to the hospital’s emergency department.", + "The chief complaint was a painful mass located in the right thigh and perineal area.", + "The patient had progressed pain and paresthesia to the right thigh and right shin.", + "The patient seemed ill but not toxic.", + "There was no history of fever.", + "There was no history of abdominal pain.", + "There was no history of digestive dysfunctions.", + "There was no history of chest pain.", + "There was no history of cough.", + "There was no history of hemoptysis.", + "There was no history of urticarial.", + "The vital signs were in a normal range.", + "There was no family history.", + "Physical examination showed the skin over the mass had no discoloration.", + "The size of the mass was around 5.7 cm long.", + "The blood tests were normal.", + "The lab results showed no eosinophilia.", + "The result of the ultrasonography examination was a cystic mass with suspicion toward femoral hernia.", + "The result of secondary workups was a multi-lobular cystic mass with no connection to the abdominal region.", + "The result suggested a hydatid cyst.", + "The patient underwent surgery under spinal anesthesia.", + "A cystic mass with ecto- and endocyst with clinical similarity to a hydatid cyst was removed.", + "The cyst was removed with wide margins and without penetration of the cyst wall.", + "The removed specimen was sent for histological examination.", + "The first impression was cystic hydatidosis.", + "The received specimen in formalin consisted of a creamy-whitish colored cyst measuring 7 * 5 * 3 cm.", + "The cyst was filled by multiple variable-sized creamy cysts.", + "The cyst consisted of three layers.", + "The outermost layer was a fibrous pericyst layer.", + "The middle layer was a laminated ectocyst layer.", + "The inner layer was a hyaline and acellular endocyst as the germinative layer.", + "The germinative layer encompassed daughter cysts and brood capsules with scolices.", + "There may be granulomatous palisading reaction.", + "There may be pseudocyst formation as seen in cutaneous lesions.", + "Post-surgical abdominal and thoracic ultrasonography screening were used to exclude recurrence.", + "Albendazole 400 mg PO BID was prescribed for 3–6 months.", + "An 18-months follow-up demonstrated no reoccurrence.", + "An 18-months follow-up demonstrated no other site of cystic hydatidosis.", + "After a year of routine follow-up, the patient did not demonstrate any signs of recurrence.", + "After a year of routine follow-up, the patient did not demonstrate any adverse effect of surgery.", + "The patient was entirely well after a year of routine follow-up." + ], + "summary": "Our case is a 55-year-old woman with the chief complaint of a painful mass in the right thigh and perineal area with progressed pain and paresthesia to the right thigh and shin. The patient had no history of fever, abdominal pain, digestive dysfunctions, or chest pain. The vital signs were normal, and there was no family history. Physical examination showed that the skin over the mass had no discoloration, and the size was around 5.7 cm long. The result of the ultrasonography examination showed a cystic mass with suspicion toward the femoral hernia. After a CT scan, the result of secondary workups was a multi-lobular cystic mass with no connection to the abdominal region, which suggested a hydatid cyst. The patient underwent spinal anesthesia and surgery, a cystic mass with ecto- and endocyst, with clinical similarity to a hydatid cyst, was removed with wide margins, and the cyst wall was kept intact. In the next step, the specimen was sent for histological examination that confirmed cystic hydatidosis. The Post-surgical Abdominal and thoracic Ultrasonography screening were used to exclude relapse, and medical therapy was given for 3-6 months. An 18-months follow-up demonstrated no reoccurrence and no newly formed cyst.", + "summary_subclaims": [ + "The patient is a 55-year-old woman.", + "The chief complaint was a painful mass in the right thigh and perineal area.", + "The patient had no history of fever.", + "The patient had no history of abdominal pain.", + "The patient had no history of chest pain.", + "The vital signs were normal.", + "There was no family history.", + "Physical examination showed the skin over the mass had no discoloration.", + "The size of the mass was around 5.7 cm long.", + "Ultrasonography showed a cystic mass with suspicion toward the femoral hernia.", + "CT scan showed a multi-lobular cystic mass with no connection to the abdominal region.", + "The CT scan result suggested a hydatid cyst.", + "The patient underwent spinal anesthesia and surgery.", + "A cystic mass with ecto- and endocyst was removed with wide margins.", + "The cyst wall was kept intact.", + "The specimen was sent for histological examination.", + "Histological examination confirmed cystic hydatidosis.", + "Post-surgical abdominal and thoracic ultrasonography screening were used to exclude relapse.", + "Medical therapy was given for 3-6 months.", + "An 18-month follow-up demonstrated no reoccurrence.", + "An 18-month follow-up demonstrated no newly formed cyst." + ] + }, + { + "id": "multiclinsum_test_2741_en.txt", + "fulltext": "A 21-year-old female of Sukuma ethnicity from the northern region of Tanzania presented at Bugando Medical Centre (BMC) outpatient clinic in Mwanza city with complaints of abdominal distension and pain, fever and abnormal vaginal discharge for the past 3 weeks. She was apparently lactating for the previous 8 months after cesarean section delivery of her first child. On physical examination, she appeared to be weak, febrile of about 38.5 °C with blood pressure of 110/70 mmHg. She was a blood group ‘A’ rhesus positive and her hemoglobin level was 6.3 g/dl.\nOn abdominal examination, a sub-umbilical midline scar was seen, and palpable suprapubic mass of about 16 weeks size of the uterus. The mass was soft, tender and mobile. The digital pelvic and vaginal examination elicited a closed cervix with tenderness on mobility and a non-bulging posterior fornix. There was no adnexal mass detected and gloved finger stained with pus-like discharge. Pelvic gynecological ultrasound suggested pelvic abscess .\nPatient was counseled for emergency laparotomy. Intraoperatively, the uterus was found to be bulky with discharging sinus on left fundal position. Both ovaries were healthy-looking and there was no fluid in the pouch of Douglas. The transverse incision was made on the uterus at the level of the discharging sinus. The yellowish mucinous tenacious materials with hairy tissues were observed. The decision to perform a total hysterectomy was reached; in which the removed uterus had hairs and sticky sebaceous matter found freely in the cavity. After surgery, the patient was transfused one unit of blood and intravenous antibiotics ceftriaxone, Gentamycin and Metronidazole were given with an addition of prophylactic Heparin. The patient had an uneventful recovery.\nThe sample was sent for histological examination. At the pathology department, the bisected uterus of 18 cm × 9 cm × 4 cm with no adnexa was identified. There was a cystic mass of 10 cm on the left fundal position in the myometrium containing hairs, sebaceous material, and pus.\nThe tissue sample was selected and sections were stained by Hematoxylin and Eosin (H&E) and observed by a light microscopy. Histology revealed a cyst in a myometrium contained keratin debris, and it was lined by squamous epithelium with dermal skin appendages with areas of denudation with lymphocyte and neutrophil infiltrate. The myometrium and endometrium was normal. Diagnosis of infected mature teratoma (dermoid cyst) was made .\nThe patient has not shown any sign of disease recurrence for 8 months following hospital discharge.", + "fulltext_subclaims": [ + "The patient is a 21-year-old female of Sukuma ethnicity from the northern region of Tanzania.", + "She presented at Bugando Medical Centre outpatient clinic in Mwanza city.", + "She had complaints of abdominal distension and pain, fever, and abnormal vaginal discharge for the past 3 weeks.", + "She was lactating for the previous 8 months after cesarean section delivery of her first child.", + "On physical examination, she appeared to be weak and febrile of about 38.5 °C.", + "Her blood pressure was 110/70 mmHg.", + "She was blood group ‘A’ rhesus positive.", + "Her hemoglobin level was 6.3 g/dl.", + "On abdominal examination, a sub-umbilical midline scar was seen.", + "A palpable suprapubic mass of about 16 weeks size of the uterus was found.", + "The mass was soft, tender, and mobile.", + "Digital pelvic and vaginal examination elicited a closed cervix with tenderness on mobility.", + "There was a non-bulging posterior fornix.", + "There was no adnexal mass detected.", + "Gloved finger stained with pus-like discharge.", + "Pelvic gynecological ultrasound suggested pelvic abscess.", + "The patient was counseled for emergency laparotomy.", + "Intraoperatively, the uterus was found to be bulky with a discharging sinus on the left fundal position.", + "Both ovaries were healthy-looking.", + "There was no fluid in the pouch of Douglas.", + "A transverse incision was made on the uterus at the level of the discharging sinus.", + "Yellowish mucinous tenacious materials with hairy tissues were observed.", + "The decision to perform a total hysterectomy was reached.", + "The removed uterus had hairs and sticky sebaceous matter found freely in the cavity.", + "The patient was transfused one unit of blood.", + "Intravenous antibiotics ceftriaxone, Gentamycin, and Metronidazole were given.", + "Prophylactic Heparin was given.", + "The patient had an uneventful recovery.", + "The sample was sent for histological examination.", + "The bisected uterus was 18 cm × 9 cm × 4 cm with no adnexa.", + "There was a cystic mass of 10 cm on the left fundal position in the myometrium.", + "The cystic mass contained hairs, sebaceous material, and pus.", + "The tissue sample was selected and sections were stained by Hematoxylin and Eosin (H&E).", + "The tissue was observed by light microscopy.", + "Histology revealed a cyst in the myometrium contained keratin debris.", + "The cyst was lined by squamous epithelium with dermal skin appendages.", + "There were areas of denudation with lymphocyte and neutrophil infiltrate.", + "The myometrium and endometrium were normal.", + "Diagnosis of infected mature teratoma (dermoid cyst) was made.", + "The patient has not shown any sign of disease recurrence for 8 months following hospital discharge." + ], + "summary": "We report a case of a 21-year-old female of Sukuma ethnicity from the northern region of Tanzania who presented with abdominal pain and distension, fever, and abnormal vaginal discharge for the previous three weeks. The patient was also lactating for the previous 8 months following cesarean section delivery. Pelvic ultrasound suggested pelvic abscess but after laparotomy and histological analysis of a bulky uterus removed a diagnosis of mature uterine teratoma was confirmed.", + "summary_subclaims": [ + "The patient is a 21-year-old female.", + "The patient is of Sukuma ethnicity.", + "The patient is from the northern region of Tanzania.", + "The patient had abdominal pain and distension.", + "The patient had fever.", + "The patient had abnormal vaginal discharge.", + "The symptoms had been present for the previous three weeks.", + "The patient was lactating.", + "The patient had been lactating for the previous 8 months.", + "The patient had a cesarean section delivery.", + "Pelvic ultrasound suggested pelvic abscess.", + "After laparotomy and histological analysis of a bulky uterus, a diagnosis of mature uterine teratoma was confirmed." + ] + }, + { + "id": "multiclinsum_test_2456_en.txt", + "fulltext": "A 27-year-old Thai male with AIDS from Saraburi Province presented with acute abdominal pain that had lasted for 4 days. He originated from Mukdahan Province, in Northeastern Thailand, but had moved to Saraburi Province which is situated in the southern part of Northeastern Thailand, 200 km from Bangkok. He denied other travel histories outside these areas during the past year. He was diagnosed with AIDS 2 months before at another hospital, which recorded an initial CD4 count of 91 cells/mm3 (unknown percentage and HIV viral load) and no complete immune status evaluation was performed. At the time, he presented with respiratory distress which was later identified as pneumocystis pneumonia and presumptive smear-negative pulmonary tuberculosis. He was given a 3-week course of trimethoprim/sulfamethoxazole, and anti-tuberculosis treatment consisting of isoniazid, rifampicin, pyrazinamide, and ethambutol during hospitalization. Anti-retroviral therapy (ART) comprising tenofovir disoproxil fumarate, emtricitabine, and efavirenz was introduced 2 weeks later when he was an outpatient. The anti-tuberculosis regimen was adjusted to isoniazid, rifampicin, ethambutol, and levofloxacin after 4 days, and a chest radiograph demonstrated complete resolution of prior pulmonary opacities after 50 days of treatment. He reported 100% adherence to both anti-tuberculosis treatment and ART and no other new medications had been added to the regimen. The CD4 count 8 weeks before this admission was 91 cells/mm3 (unknown percentage).\nAt this admission, he presented with abdominal pain mainly in the left upper quadrant that he described as a dull ache, without radiation. The pain was not related to eating food, physical activity, or position. He reported no other associated gastrointestinal complaints such as diarrhea or nausea. Two days later, he developed a high-grade fever without chills, with the highest temperature of 38.9 °C. Abdominal pain persisted and partially responded to acetaminophen. In response to this, he attended the emergency department where a physical examination revealed a blood pressure of 120/75 mmHg, a heart rate of 110 beats/min, a temperature of 38.7 °C, and a respiration rate of 20 breaths/min. His abdomen was soft, normal bowel sounds were heard, but tenderness on palpation in the left upper quadrant was evident. The spleen could not be palpated. The remaining physical examination was unremarkable including a negative complete skin examination, with no cutaneous lesions on his face, trunk, or extremities, and a neurological examination within normal limits.\nInitial laboratory investigations revealed hemoglobin levels of 9.8 g/dL, a white blood cell count of 14,000 cells/mm3, and a platelet count of 225,000 cells/mm3 on a complete blood count. Serum galactomannan (GM) levels by Platelia enzyme-linked immunosorbent assay (ELISA) (BioRad)® were 6.84. The CD4 count on admission was 272 cells/mm3 (19%). A fungal blood culture obtained on hospital day 1 grew white to tan-colored, velvety and flat colonies with red soluble pigment on day 9. Direct microscopic examination of the colonies with lactophenol cotton blue staining demonstrated septate hyphae and smooth conidia aloft phialides directly borne on metulae . A bone marrow culture grew similar colonies to the blood specimen on day 12 after the procedure. Contrast-enhanced computed tomography of the abdomen revealed a small hypodense lesion with a thin enhancing rim at the spleen and extensive intra-abdominal lymphadenopathy . At the time, the patient was not able to provide sputum sample for culture and due to the high-risk procedure, intra-abdominal lymph node biopsy for culture and histologic analysis was not performed.\nBecause of a concern of disseminated fungal infection on admission, empirical intravenous amphotericin B deoxycholate was given at a dose of 1.5 mg/kg/day for 7 days. This was switched to liposomal amphotericin B at 3.2 mg/kg/day in response to acute kidney injury for a total of 21 days. Before discharge, a loading dose of itraconazole was initiated at 600 mg/day for 3 days, then 400 mg/day for the maintenance phase. Of note, plasma itraconazole levels drawn on day 4 were 0.13 mcg/mL, with the highest value throughout the treatment course of 0.21 mcg/mL. The patient continued to improve clinically and was discharged from the hospital after 29 days. Repeat imaging was initially planned at 6 months but was deferred at the patient’s request. Serum GM levels 9 months after therapy had declined to 0.11, and he remained asymptomatic at the 12-month follow-up.", + "fulltext_subclaims": [ + "The patient is a 27-year-old Thai male with AIDS.", + "He presented with acute abdominal pain lasting for 4 days.", + "He originated from Mukdahan Province, in Northeastern Thailand.", + "He had moved to Saraburi Province, which is 200 km from Bangkok.", + "He denied other travel histories outside these areas during the past year.", + "He was diagnosed with AIDS 2 months before at another hospital.", + "The initial CD4 count was 91 cells/mm3.", + "No complete immune status evaluation was performed.", + "He presented with respiratory distress which was later identified as pneumocystis pneumonia.", + "He was given a 3-week course of trimethoprim/sulfamethoxazole.", + "Anti-tuberculosis treatment consisted of isoniazid, rifampicin, pyrazinamide, and ethambutol.", + "Anti-retroviral therapy was introduced 2 weeks later when he was an outpatient.", + "The anti-tuberculosis regimen was adjusted to isoniazid, rifampicin, ethambutol, and levofloxacin after 4 days.", + "A chest radiograph demonstrated complete resolution of prior pulmonary opacities after 50 days of treatment.", + "He reported 100% adherence to both anti-tuberculosis treatment and ART.", + "The CD4 count 8 weeks before this admission was 91 cells/mm3.", + "He presented with abdominal pain mainly in the left upper quadrant.", + "The pain was not related to eating food, physical activity, or position.", + "He reported no other associated gastrointestinal complaints such as diarrhea or nausea.", + "Two days later, he developed a high-grade fever without chills.", + "The highest temperature was 38.9 °C.", + "Abdominal pain persisted and partially responded to acetaminophen.", + "A physical examination revealed a blood pressure of 120/75 mmHg.", + "The heart rate was 110 beats/min.", + "The temperature was 38.7 °C.", + "The respiration rate was 20 breaths/min.", + "The abdomen was soft with normal bowel sounds.", + "Tenderness on palpation in the left upper quadrant was evident.", + "The spleen could not be palpated.", + "The remaining physical examination was unremarkable.", + "Initial laboratory investigations revealed hemoglobin levels of 9.8 g/dL.", + "The white blood cell count was 14,000 cells/mm3.", + "The platelet count was 225,000 cells/mm3.", + "Serum galactomannan levels were 6.84.", + "The CD4 count on admission was 272 cells/mm3.", + "A fungal blood culture obtained on hospital day 1 grew white to tan-colored, velvety and flat colonies with red soluble pigment.", + "Direct microscopic examination of the colonies demonstrated septate hyphae and smooth conidia aloft phialides directly borne on metulae.", + "A bone marrow culture grew similar colonies to the blood specimen.", + "Contrast-enhanced computed tomography of the abdomen revealed a small hypodense lesion with a thin enhancing rim at the spleen.", + "Extensive intra-abdominal lymphadenopathy was noted.", + "The patient was not able to provide a sputum sample for culture.", + "Intra-abdominal lymph node biopsy was not performed due to the high-risk procedure.", + "Empirical intravenous amphotericin B deoxycholate was given at a dose of 1.5 mg/kg/day for 7 days.", + "This was switched to liposomal amphotericin B at 3.2 mg/kg/day in response to acute kidney injury.", + "A loading dose of itraconazole was initiated at 600 mg/day for 3 days.", + "Plasma itraconazole levels drawn on day 4 were 0.13 mcg/mL.", + "The highest plasma itraconazole level throughout the treatment course was 0.21 mcg/mL.", + "The patient continued to improve clinically and was discharged after 29 days.", + "Repeat imaging was initially planned at 6 months but was deferred at the patient’s request.", + "Serum GM levels 9 months after therapy had declined to 0.11.", + "He remained asymptomatic at the 12-month follow-up." + ], + "summary": "A 27-year-old male with AIDS presented with acute onset of abdominal pain for 4 days and fever for 2 days. He had been diagnosed with AIDS, pneumocystis pneumonia, and presumptive smear-negative pulmonary tuberculosis 2 months previously. His initial CD4 count was 91 cells/mm3. After a 3-week course of trimethoprim/sulfamethoxazole and anti-tuberculosis treatment, anti-retroviral therapy was initiated. Physical examination revealed left upper quadrant tenderness but no abnormal skin lesions. On this visit, his CD4 count rose to 272 cells/mm3 (19%). Computed tomography of the abdomen showed evidence of a small hypodense lesion with a thin enhancing rim at the spleen and extensive intra-abdominal lymphadenopathy. Empirical amphotericin B deoxycholate was administered in response to positive serum galactomannan, although this was switched to intravenous liposomal amphotericin B 1 week later because of acute kidney injury. Blood and bone marrow cultures for fungus grew T. marneffei on days 9 and 12, respectively. After 21 days of treatment, oral itraconazole replaced intravenous therapy. The patient was discharged home after 29 days in the hospital and continued to improve clinically at a follow-up visit as an outpatient.", + "summary_subclaims": [ + "The patient is a 27-year-old male with AIDS.", + "He had acute onset of abdominal pain for 4 days.", + "He had fever for 2 days.", + "He had been diagnosed with AIDS, pneumocystis pneumonia, and presumptive smear-negative pulmonary tuberculosis 2 months previously.", + "His initial CD4 count was 91 cells/mm3.", + "After a 3-week course of trimethoprim/sulfamethoxazole and anti-tuberculosis treatment, anti-retroviral therapy was initiated.", + "Physical examination revealed left upper quadrant tenderness.", + "On this visit, his CD4 count rose to 272 cells/mm3.", + "Computed tomography of the abdomen showed evidence of a small hypodense lesion with a thin enhancing rim at the spleen.", + "Computed tomography of the abdomen showed extensive intra-abdominal lymphadenopathy.", + "Empirical amphotericin B deoxycholate was administered in response to positive serum galactomannan.", + "This was switched to intravenous liposomal amphotericin B 1 week later because of acute kidney injury.", + "Blood and bone marrow cultures for fungus grew T. marneffei on days 9 and 12, respectively.", + "After 21 days of treatment, oral itraconazole replaced intravenous therapy.", + "The patient was discharged home after 29 days in the hospital.", + "The patient continued to improve clinically at a follow-up visit as an outpatient." + ] + }, + { + "id": "multiclinsum_test_2257_en.txt", + "fulltext": "A 69-year-old man presented to the emergency room with sudden-onset abdominal pain and nausea. He had previously undergone a hybrid laparoscopic left hemihepatectomy and splenectomy for hepatolithiasis and spherocytosis approximately 20 months earlier. Since his surgery, he had occasionally taken non-steroidal anti-inflammatory drugs (NSAIDs), loxoprofen as per his prescription. During the 3 months before his current presentation, he had discontinued taking proton pump inhibitors, at his request.\nAbdominal computed tomography images revealed a deformity of the duodenal bulb and a markedly dilated stomach, containing food residue ; free air in the abdominal cavity was not detected. A fibroscopic upper gastrointestinal examination revealed a giant ulcer with a prominent crater in the inferior wall of the bulb. In addition, a foreign body was detected at the ulcer floor and was strongly suspected of being a ligature associated with the previous left hemihepatectomy . The foreign body was eliminated, and an endoscopic biopsy was performed. Histopathological examination of the biopsy showed a simple, active ulcer. The patient received conservative therapy with a proton pump inhibitor and recovered immediately.", + "fulltext_subclaims": [ + "The patient is a 69-year-old man.", + "He presented to the emergency room with sudden-onset abdominal pain and nausea.", + "He had previously undergone a hybrid laparoscopic left hemihepatectomy and splenectomy.", + "The surgery was for hepatolithiasis and spherocytosis.", + "The surgery occurred approximately 20 months earlier.", + "He had occasionally taken non-steroidal anti-inflammatory drugs (NSAIDs), loxoprofen as per his prescription.", + "He had discontinued taking proton pump inhibitors 3 months before his current presentation.", + "Abdominal computed tomography images revealed a deformity of the duodenal bulb.", + "Abdominal computed tomography images revealed a markedly dilated stomach containing food residue.", + "Free air in the abdominal cavity was not detected.", + "A fibroscopic upper gastrointestinal examination revealed a giant ulcer with a prominent crater in the inferior wall of the bulb.", + "A foreign body was detected at the ulcer floor.", + "The foreign body was strongly suspected of being a ligature associated with the previous left hemihepatectomy.", + "The foreign body was eliminated.", + "An endoscopic biopsy was performed.", + "Histopathological examination of the biopsy showed a simple, active ulcer.", + "The patient received conservative therapy with a proton pump inhibitor.", + "The patient recovered immediately." + ], + "summary": "A 69-year-old man with a history of left hemihepatectomy 20 months previously presented to the emergency room with sudden-onset abdominal pain and nausea. An upper gastrointestinal examination with a fiberscope revealed a giant ulcer in the duodenal bulb. In addition, a foreign body was detected at the ulcer floor and was strongly suspected of being a ligature from previous hemihepatectomy.", + "summary_subclaims": [ + "The patient is a 69-year-old man.", + "The patient had a left hemihepatectomy 20 months previously.", + "The patient presented with sudden-onset abdominal pain.", + "The patient had nausea.", + "An upper gastrointestinal examination with a fiberscope was performed.", + "A giant ulcer was found in the duodenal bulb.", + "A foreign body was detected at the ulcer floor.", + "The foreign body was strongly suspected of being a ligature from previous hemihepatectomy." + ] + }, + { + "id": "multiclinsum_test_1909_en.txt", + "fulltext": "A 42-year-old man with no other significant medical history was diagnosed with metastatic melanoma that was BRAF V617F mutated, with metastasis to liver, lung and adrenal glands. He had a past history of early stage melanoma that was initially diagnosed eight years ago, for which he underwent wide local excision with a negative sentinel lymph node biopsy. He did not receive any adjuvant chemo or immunotherapy. Subsequently, he started noticing multiple cutaneous lesions that were positive for melanoma, which led to a complete staging work up that revealed metastatic disease. Patient had an excellent performance status with no known history of endocrinopathies, including diabetes mellitus. He had normal fasting glucose levels, which was checked by his primary care physician. He was started on first line systemic immunotherapy with the combination of ipilimumab and nivolumab. He completed three out of the four planned cycles of combined regimen, that was administered at ipilimumab 3 mg/kg IV and nivolumab 1 mg/kg IV every three weeks, prior to emergency room presentation. Chief complaints at this presentation included intractable nausea, vomiting and diarrhea. He reported to having more than 8 loose bowel movements a day, some of which were associated with blood streaking. In the ER his serum glucose was elevated to 728 mg/dL and he was in DKA with significant anion gap metabolic acidosis, for which he was admitted to intensive care unit for further management. He was given intravenous insulin as bolus and started on insulin drip along with IV fluids as per DKA protocol. His blood glucose levels subsequently improved. Hemoglobin A1c (HbA1c) level from admission was 6.5%, indicating a rather new onset diabetes mellitus. Stool studies returned negative for infectious etiologies and he was started on anti-motility agents (Imodium and Lomotil), which failed to provide any relief from diarrhea. Computerized tomography of abdomen and pelvis showed pan-colitis and he was started on prednisone 1 mg/kg daily for presumed immune mediated colitis. Despite steroids he continued to have diarrhea, which were intermittently bloody. He was then started on octreotide (50 mcg subcutaneous injection TID, which was later increased to 100 mcg TID), with which his diarrhea was controlled. We had planned to start him on infliximab (a tumor necrosis factor inhibitor) if he failed the octreotide trial.\nSubsequently, he was discharged home on an insulin regimen for presumed new onset insulin dependent diabetes mellitus (IDDM) and prednisone taper for colitis. Initially he had trouble controlling blood glucose levels while on prednisone taper. But, once he was off prednisone, his IDDM was better controlled. One month later into follow up repeat hemoglobin A1c was 7.9%, but his glucose levels were much better controlled. Since no testing for autoimmune diabetes was done during his initial presentation, anti-GAD65 antibody, ZnT8 antibody, and IA-2 antibody testing was done during his subsequent clinic follow up. Anti- GAD65 antibody was <5 IU/ml, ZnT8 antibody was <10 U/Ml, and IA-2 antibody was <0.8 U/ml, all being within normal limits. Though DKA is more common with autoimmune or type 1 diabetes mellitus, it can be seen with type 2 diabetes mellitus. Since, patient had no evidence of diabetes or pre-diabetes prior to immunotherapy, we think treatment with combined checkpoint blockade is what led to DKA.", + "fulltext_subclaims": [ + "The patient is a 42-year-old man.", + "He has no other significant medical history.", + "He was diagnosed with metastatic melanoma.", + "The melanoma was BRAF V617F mutated.", + "The melanoma had metastasis to liver, lung, and adrenal glands.", + "He had a past history of early stage melanoma.", + "The early stage melanoma was diagnosed eight years ago.", + "He underwent wide local excision for the early stage melanoma.", + "The sentinel lymph node biopsy was negative.", + "He did not receive any adjuvant chemo or immunotherapy.", + "He started noticing multiple cutaneous lesions that were positive for melanoma.", + "A complete staging work up revealed metastatic disease.", + "He had an excellent performance status.", + "He had no known history of endocrinopathies, including diabetes mellitus.", + "He had normal fasting glucose levels.", + "He was started on first line systemic immunotherapy with the combination of ipilimumab and nivolumab.", + "He completed three out of the four planned cycles of the combined regimen.", + "The regimen was administered at ipilimumab 3 mg/kg IV and nivolumab 1 mg/kg IV every three weeks.", + "He presented to the emergency room with intractable nausea, vomiting, and diarrhea.", + "He reported more than 8 loose bowel movements a day, some with blood streaking.", + "In the ER, his serum glucose was elevated to 728 mg/dL.", + "He was in DKA with significant anion gap metabolic acidosis.", + "He was admitted to the intensive care unit.", + "He was given intravenous insulin as bolus and started on insulin drip.", + "He was started on IV fluids as per DKA protocol.", + "His blood glucose levels subsequently improved.", + "His HbA1c level from admission was 6.5%.", + "Stool studies returned negative for infectious etiologies.", + "He was started on anti-motility agents (Imodium and Lomotil).", + "The anti-motility agents failed to provide any relief from diarrhea.", + "CT of abdomen and pelvis showed pan-colitis.", + "He was started on prednisone 1 mg/kg daily for presumed immune mediated colitis.", + "He continued to have diarrhea, which were intermittently bloody.", + "He was started on octreotide 50 mcg subcutaneous injection TID.", + "The octreotide dose was later increased to 100 mcg TID.", + "His diarrhea was controlled with octreotide.", + "We had planned to start him on infliximab if he failed the octreotide trial.", + "He was discharged home on an insulin regimen for presumed new onset insulin dependent diabetes mellitus.", + "He was discharged on prednisone taper for colitis.", + "Initially, he had trouble controlling blood glucose levels while on prednisone taper.", + "Once he was off prednisone, his IDDM was better controlled.", + "One month later, repeat hemoglobin A1c was 7.9%.", + "Anti-GAD65 antibody was <5 IU/ml.", + "ZnT8 antibody was <10 U/Ml.", + "IA-2 antibody was <0.8 U/ml.", + "DKA is more common with autoimmune or type 1 diabetes mellitus.", + "DKA can be seen with type 2 diabetes mellitus.", + "The patient had no evidence of diabetes or pre-diabetes prior to immunotherapy.", + "We think treatment with combined checkpoint blockade led to DKA." + ], + "summary": "We report the case of a 42 year old man with metastatic melanoma and no prior history of diabetes mellitus, who presented with diabetic ketoacidosis (DKA) after 3 cycles of combination checkpoint inhibitor therapy using nivolumab and ipilimumab. New onset diabetes mellitus was diagnosed on the basis of elevated hemoglobin A1c, in the absence of prior personal or family history. Autoimmune or type 1 diabetes mellitus was ruled out with normal levels of anti-glutamic acid decarboxylase 65 (GAD65) antibody, zinc transporter 8 (ZnT8) antibody, and islet antigen-2 (IA-2) antibody.", + "summary_subclaims": [ + "The patient was a 42 year old man.", + "The patient had metastatic melanoma.", + "The patient had no prior history of diabetes mellitus.", + "The patient presented with diabetic ketoacidosis.", + "The patient had received 3 cycles of combination checkpoint inhibitor therapy.", + "The combination therapy used nivolumab and ipilimumab.", + "New onset diabetes mellitus was diagnosed.", + "The diagnosis was based on elevated hemoglobin A1c.", + "There was no prior personal or family history of diabetes.", + "Autoimmune or type 1 diabetes mellitus was ruled out.", + "Anti-glutamic acid decarboxylase 65 (GAD65) antibody levels were normal.", + "Zinc transporter 8 (ZnT8) antibody levels were normal.", + "Islet antigen-2 (IA-2) antibody levels were normal." + ] + }, + { + "id": "multiclinsum_test_1451_en.txt", + "fulltext": "A 44-year-old Guatemalan woman presented to our outpatient clinic with a chief complaint of left knee pain for the last 6 months. One month prior our patient had consulted with an outside physician, who prescribed her with 300 mg of carbamazepine, 5 mg of prednisone every 24 hours, and ibuprofen every 8 hours as needed. The symptoms did not resolve and our patient increased the dose to 600 mg of carbamazepine and 20 mg of prednisone 7 days before consulting. She suddenly interrupted prednisone 3 days before consulting, because she felt this was making her pain worse. At the consultation, our patient complained of left knee pain, fatigue, and bilateral lower limb cramps. No pertinent medical, surgical, allergic, family, and psychosocial history was recorded and her vital signs were within normal limits (blood pressure of 118/64 mmHg; heart rate of 75/minute; respiratory rate of 14 beats/minute; temperature at 98.9 °Fahrenheit). Our patient was on day 12 of her menstrual cycle. A physical examination revealed mild facial edema, multiple port-wine stains on her upper and lower extremities associated with mild hypertrophy of the calves , more prominent on the right side with mild edema, the rest of the physical examination was non-contributory. Imaging and routine blood studies were requested. Our patient was seen the next day at the office with the laboratory results .\nOur patient presented with only a complaint of fatigue at this visit, however, no neurologic or physical disabilities were recorded, and her vital signs were within normal limits.\nOur patient was sent to the emergency department (ED) for electrolyte imbalance correction and for other diagnostic studies. In the ED, a 12-lead electrocardiogram did not show any electric abnormalities, her urinary Na+ (UNa+) was 164 mmol/L (normal 40–220 mmol/L), and osmolality 328 mmol/kg (50–1200 mmol/kg). No carbamazepine serum levels were recorded due to lack of reactive in the hospital. Our patient was diagnosed with syndrome of inappropriate antidiuretic hormone secretion (SIADH) secondary to carbamazepine use, hypokalemia secondary to corticosteroid therapy, and Klippel-Trénaunay-Weber (KTW) syndrome. Patient orders were to discontinue carbamazepine, fluid restriction to 1.5 L/day and intravenous potassium (K+) slow correction. She was discharged 3 days later with Na+ 128 mmol/L, K+ 4.6 mmol/L, and serum osmolality 265 mmol/kg. Our patient was seen in the office 1 week after discharge: she no longer felt fatigued, her cramps were not present and her left knee pain had mildly improved with acetaminophen use and local nonsteroidal anti-inflammatory drug (NSAID) cream. Her left knee pain was attributed to the KTW syndrome. She was not taking carbamazepine and prednisone at the time of the follow-up. Electrolyte studies revealed Na+ 138 mmol/L, K 4.6 mmol/L, and serum osmolality at 276 mmol/kg.", + "fulltext_subclaims": [ + "The patient is a 44-year-old Guatemalan woman.", + "She presented with left knee pain for the last 6 months.", + "One month prior, she consulted with an outside physician.", + "The outside physician prescribed 300 mg of carbamazepine.", + "The outside physician prescribed 5 mg of prednisone every 24 hours.", + "The outside physician prescribed ibuprofen every 8 hours as needed.", + "The symptoms did not resolve.", + "She increased the dose to 600 mg of carbamazepine.", + "She increased the dose to 20 mg of prednisone.", + "She suddenly interrupted prednisone 3 days before consulting.", + "She felt prednisone was making her pain worse.", + "At the consultation, she complained of left knee pain.", + "At the consultation, she complained of fatigue.", + "At the consultation, she complained of bilateral lower limb cramps.", + "No pertinent medical, surgical, allergic, family, and psychosocial history was recorded.", + "Her vital signs were within normal limits.", + "Her blood pressure was 118/64 mmHg.", + "Her heart rate was 75/minute.", + "Her respiratory rate was 14 beats/minute.", + "Her temperature was 98.9 °Fahrenheit.", + "She was on day 12 of her menstrual cycle.", + "A physical examination revealed mild facial edema.", + "A physical examination revealed multiple port-wine stains on her upper and lower extremities.", + "The port-wine stains were associated with mild hypertrophy of the calves.", + "The hypertrophy was more prominent on the right side.", + "The right side had mild edema.", + "The rest of the physical examination was non-contributory.", + "Imaging and routine blood studies were requested.", + "She was seen the next day at the office with the laboratory results.", + "She presented with only a complaint of fatigue at this visit.", + "No neurologic or physical disabilities were recorded.", + "Her vital signs were within normal limits.", + "She was sent to the emergency department for electrolyte imbalance correction.", + "She was sent to the emergency department for other diagnostic studies.", + "A 12-lead electrocardiogram did not show any electric abnormalities.", + "Her urinary Na+ (UNa+) was 164 mmol/L.", + "The normal range for UNa+ is 40–220 mmol/L.", + "Her osmolality was 328 mmol/kg.", + "The normal range for osmolality is 50–1200 mmol/kg.", + "No carbamazepine serum levels were recorded due to lack of reactive in the hospital.", + "She was diagnosed with syndrome of inappropriate antidiuretic hormone secretion (SIADH) secondary to carbamazepine use.", + "She was diagnosed with hypokalemia secondary to corticosteroid therapy.", + "She was diagnosed with Klippel-Trénaunay-Weber (KTW) syndrome.", + "Patient orders were to discontinue carbamazepine.", + "Patient orders were fluid restriction to 1.5 L/day.", + "Patient orders were intravenous potassium (K+) slow correction.", + "She was discharged 3 days later.", + "Her Na+ at discharge was 128 mmol/L.", + "Her K+ at discharge was 4.6 mmol/L.", + "Her serum osmolality at discharge was 265 mmol/kg.", + "She was seen in the office 1 week after discharge.", + "She no longer felt fatigued.", + "Her cramps were not present.", + "Her left knee pain had mildly improved with acetaminophen use.", + "Her left knee pain had mildly improved with local nonsteroidal anti-inflammatory drug (NSAID) cream.", + "Her left knee pain was attributed to the KTW syndrome.", + "She was not taking carbamazepine at the time of the follow-up.", + "She was not taking prednisone at the time of the follow-up.", + "Electrolyte studies revealed Na+ 138 mmol/L.", + "Electrolyte studies revealed K 4.6 mmol/L.", + "Electrolyte studies revealed serum osmolality at 276 mmol/kg." + ], + "summary": "A 44-year-old Guatemalan woman presented to our outpatient clinic with a chief complaint of left knee pain. One month prior, our patient had previously consulted with an outside physician, who prescribed her with 300 mg of carbamazepine, 5 mg of prednisone every 24 hours, and ibuprofen every 8 hours as needed. The symptoms did not resolve and our patient had increased the dose to 600 mg of carbamazepine and 20 mg of prednisone 7 days prior. Our patient complained of left knee pain, fatigue, and bilateral lower limb cramps. No pertinent medical history was recorded and her vital signs were within normal limits. A physical examination was non-contributory, only multiple port-wine stains in the upper and lower extremities associated with mild hypertrophy of the calves, more prominent on the right side. Laboratory studies revealed: a serum sodium level of 119 mmol/L, potassium level of 2.9 mmol/L, thyroid-secreting hormone of 1.76 mIU/m, thyroxine of 14.5 ng/dL, and serum osmolality at 247 mmol/kg. No neurologic or physical disabilities were recorded. In the emergency department, her electrolyte imbalance was corrected and other diagnostic studies revealed: a urinary sodium level of 164 mmol/L and osmolality at 328 mmol/kg. Our patient was diagnosed with syndrome of inappropriate antidiuretic hormone secretion secondary to carbamazepine use, hypokalemia secondary to corticosteroid therapy, and Klippel-Trénaunay-Weber syndrome. Carbamazepine was discontinued, fluid restriction ordered, and hypokalemia was corrected. One week after discharge, our patient no longer felt fatigued, the cramps were not present, and her left knee pain had mildly improved with acetaminophen use and local nonsteroidal anti-inflammatory cream. Electrolyte studies revealed a sodium level of 138 mmol/L, potassium level of 4.6 mmol/L, and serum osmolality at 276 mmol/L.", + "summary_subclaims": [ + "The patient is a 44-year-old Guatemalan woman.", + "The patient presented with a chief complaint of left knee pain.", + "One month prior, the patient had previously consulted with an outside physician.", + "The outside physician prescribed 300 mg of carbamazepine.", + "The outside physician prescribed 5 mg of prednisone every 24 hours.", + "The outside physician prescribed ibuprofen every 8 hours as needed.", + "The symptoms did not resolve.", + "The patient had increased the dose to 600 mg of carbamazepine 7 days prior.", + "The patient had increased the dose to 20 mg of prednisone 7 days prior.", + "The patient complained of left knee pain.", + "The patient complained of fatigue.", + "The patient complained of bilateral lower limb cramps.", + "No pertinent medical history was recorded.", + "The patient's vital signs were within normal limits.", + "A physical examination was non-contributory.", + "The patient had multiple port-wine stains in the upper and lower extremities.", + "The port-wine stains were associated with mild hypertrophy of the calves.", + "The calf hypertrophy was more prominent on the right side.", + "Laboratory studies revealed a serum sodium level of 119 mmol/L.", + "Laboratory studies revealed a potassium level of 2.9 mmol/L.", + "Laboratory studies revealed a thyroid-stimulating hormone of 1.76 mIU/mL.", + "Laboratory studies revealed thyroxine of 14.5 ng/dL.", + "Laboratory studies revealed serum osmolality at 247 mmol/kg.", + "No neurologic or physical disabilities were recorded.", + "In the emergency department, the patient's electrolyte imbalance was corrected.", + "Other diagnostic studies revealed a urinary sodium level of 164 mmol/L.", + "Other diagnostic studies revealed urinary osmolality at 328 mmol/kg.", + "The patient was diagnosed with syndrome of inappropriate antidiuretic hormone secretion secondary to carbamazepine use.", + "The patient was diagnosed with hypokalemia secondary to corticosteroid therapy.", + "The patient was diagnosed with Klippel-Trénaunay-Weber syndrome.", + "Carbamazepine was discontinued.", + "Fluid restriction was ordered.", + "Hypokalemia was corrected.", + "One week after discharge, the patient no longer felt fatigued.", + "One week after discharge, the cramps were not present.", + "One week after discharge, the left knee pain had mildly improved.", + "The improvement in left knee pain was with acetaminophen use.", + "The improvement in left knee pain was with local nonsteroidal anti-inflammatory cream.", + "Electrolyte studies one week after discharge revealed a sodium level of 138 mmol/L.", + "Electrolyte studies one week after discharge revealed a potassium level of 4.6 mmol/L.", + "Electrolyte studies one week after discharge revealed serum osmolality at 276 mmol/kg." + ] + }, + { + "id": "multiclinsum_test_3387_en.txt", + "fulltext": "A 44-year-old female patient was admitted to our hospital due to “Cognitive decline for 4 years and paroxysmal loss of consciousness with convulsion for 2 months”. Four years before admission, the patient had developed cognitive decline without obvious inducement, easily forgotten the names of her relatives and forgot what to do without headache and dizziness. Two months before admission, she had a temperature of 39.5 ◦C, and developed paroxysmal loss of consciousness with convulsion, mainly manifesting as her eyes turned up, foaming at the mouth, clenched teeth, limb twitching and unconsciousness, lasting approximately 15 minutes. She was unable to recall after the attack. This situation occurred three times. After that, she was easily distracted and could not concentrate on work. She felt depressed easily and her speech slowed, and was found incompetent for her job. Cranial magnetic resonance imaging (MRI) (plain scan) at a local hospital showed no abnormalities. She came to our clinic for further diagnosis and treatment. She had a history of Hashimoto’s thyroiditis and hypothyroidism.\n\nOn admission, her neurological examination revealed decreased verbal fluency. Cranial nerve examination was unremarkable. Her muscle strength was normal, and no other remarkable physical findings of nervous system were observed. The Glasgow coma score was normal. Physical examinations of the heart, lungs, and abdomen were unremarkable. She scored 25/30 on the Mini-Mental State Examination (MMSE), 24/30 on the Montreal Cognitive Assessment (MoCA), showing that the patient had mild cognitive impairment. Mild depression (51 points) was found after evaluation with Self-rating Depression Scale (SDS). No anxiety was found after evaluation using the Self-rating Anxiety Scale (SAS).\n\nAuxiliary examinations were performed. Lung computed tomography (CT) revealed chronic inflammation in both lungs. Cranial magnetic resonance imaging (MRI) (plain scan + enhanced) showed no abnormalities. No obvious abnormality was found in cerebral CT vascular enhancement. 24-hours ambulatory electroencephalogram was normal. The result of gynecological and abdominal ultrasound was normal.\n\nHer intracranial pressure was 80 mmH2O. CSF analysis showed normal cell count (total cell 2× 106/ L, nucleated cells 1×106 /L), protein, glucose, chloride, lactate, and adenosine deaminase were within the normal range. Gram staining, fungal smear, acid-fast staining, ink staining, and pathogen culture of CSF were all negative. Cerebrospinal fluid oligoclonal band was negative. CSF and serum samples were collected for examination of AE antibodies, including anti-NMDAR, anti-AMPAR1, anti-AMPAR2, anti-LGI1, anti-CASPR2, anti-GABABR, anti-DPPX, anti-IgLON5, anti-GlyRα1, anti-GABAARα1, anti-GABAARβ3, anti-mGluR5, anti-D2R, anti-Neurexin-3α, anti-GAD65, anti-GABAARγ2 antibody IgG (cell-based assay). The significant findings included a positive anti-GAD65 antibody (titer of 1:32) and positive anti-GABAARγ2 antibody (titer of 1:32) in the CSF, and both were negative in serum. In addition, high levels of homocysteine (16.9μmol/L; normal range:<15μmol/L), total cholesterol (5.57mmol/L; normal range:<5.18mmol/L), high-density lipoprotein (HDL) (1.8 mmol/L; normal range:1.29–1.55mmol/L), low-density lipoprotein (LDL) (3.68mmol/L; normal range: <3.37mmol/L) were presented. High level of thyroid peroxidase antibody (TPO-Ab) (228 IU/mL; normal range: <34 IU/mL) and low level of Vitamin B12 (119.4 pg/mL; normal range: 189–883 pg/mL) were presented. The results of other examinations were unremarkable.\n\nAfter being diagnosed with AE with coexisting anti-GAD and anti-GABAAR antibodies, the patient was treated with intravenous immunoglobulin (400 mg/kg/d for 5 days), intravenous methylprednisolone (at dose of 1000mg/d, 500mg/d, 250mg/d, 120mg/d, 80mg/d for 3 days respectively) and levetiracetam (0.5g PO bid). Twenty days later, her symptoms, such as cognitive decline, gradually improved during the treatment and no seizures occurred. After treatment for 20 days, she scored 26/30 on the Montreal Cognitive Assessment at discharge. Oral prednisone acetate tablets at dose of 1mg/kg/d, reduced by 5 mg every two weeks, were continued. At her 6-month follow-up, her epileptic seizures disappeared, cognitive function was normal, and speed improved.", + "fulltext_subclaims": [ + "The patient is a 44-year-old female.", + "The patient had cognitive decline for 4 years.", + "The patient had paroxysmal loss of consciousness with convulsion for 2 months.", + "Four years before admission, the patient had developed cognitive decline without obvious inducement.", + "Two months before admission, she had a temperature of 39.5 ◦C.", + "She developed paroxysmal loss of consciousness with convulsion.", + "The convulsions lasted approximately 15 minutes.", + "She was unable to recall after the attack.", + "This situation occurred three times.", + "After the attacks, she was easily distracted and could not concentrate on work.", + "She felt depressed easily and her speech slowed.", + "She was found incompetent for her job.", + "Cranial MRI (plain scan) at a local hospital showed no abnormalities.", + "She had a history of Hashimoto’s thyroiditis.", + "She had a history of hypothyroidism.", + "On admission, cranial nerve examination was unremarkable.", + "The patient scored 25/30 on the Mini-Mental State Examination.", + "The patient scored 24/30 on the Montreal Cognitive Assessment.", + "Mild depression was found after evaluation with the Self-rating Depression Scale.", + "No anxiety was found after evaluation using the Self-rating Anxiety Scale.", + "Lung CT revealed chronic inflammation in both lungs.", + "Cranial MRI (plain scan + enhanced) showed no abnormalities.", + "No obvious abnormality was found in cerebral CT vascular enhancement.", + "24-hours ambulatory electroencephalogram was normal.", + "The result of gynecological and abdominal ultrasound was normal.", + "CSF analysis showed normal cell count.", + "CSF protein, glucose, chloride, lactate, and adenosine deaminase were within the normal range.", + "Gram staining, fungal smear, acid-fast staining, ink staining, and pathogen culture of CSF were all negative.", + "Cerebrospinal fluid oligoclonal band was negative.", + "CSF anti-GAD65 antibody was positive (titer of 1:32).", + "CSF anti-GABAARγ2 antibody was positive (titer of 1:32).", + "Serum anti-GAD65 antibody was negative.", + "Serum anti-GABAARγ2 antibody was negative.", + "Homocysteine level was 16.9μmol/L.", + "Total cholesterol was 5.57mmol/L.", + "High-density lipoprotein was 1.8 mmol/L.", + "Low-density lipoprotein was 3.68mmol/L.", + "Thyroid peroxidase antibody was 228 IU/mL.", + "Vitamin B12 was 119.4 pg/mL.", + "The patient was diagnosed with AE with coexisting anti-GAD and anti-GABAAR antibodies.", + "The patient was treated with intravenous immunoglobulin.", + "The patient was treated with intravenous methylprednisolone.", + "The patient was treated with levetiracetam.", + "Twenty days later, her symptoms, such as cognitive decline, gradually improved.", + "After treatment for 20 days, she scored 26/30 on the Montreal Cognitive Assessment at discharge.", + "Oral prednisone acetate tablets were continued at dose of 1mg/kg/d.", + "At her 6-month follow-up, her epileptic seizures disappeared.", + "At her 6-month follow-up, cognitive function was normal." + ], + "summary": "A 44-year-old female patient presented to our hospital due to cognitive decline for 4 years, seizures, slowed speech and depression for 2 months. Based on her clinical manifestations and laboratory assessment results (positive anti-GAD and anti-GABAAR antibodies), she was diagnosed as AE with coexisting anti-GAD and anti-GABAAR antibodies. After treatment with intravenous methylprednisolone (at dose of 1000mg/d, 500mg/d, 250mg/d, 120mg/d, 80mg/d for 3 days respectively) and intravenous immunoglobulin (400 mg/kg/d for 5 days), her symptoms gradually improved with exception for the slowed speech. Oral prednisone acetate was continued after discharge, her symptoms of slowed speech improved at 6-month follow-up.", + "summary_subclaims": [ + "The patient is a 44-year-old female.", + "She presented due to cognitive decline for 4 years.", + "She had seizures, slowed speech, and depression for 2 months.", + "She was diagnosed with AE with coexisting anti-GAD and anti-GABAAR antibodies.", + "She received intravenous methylprednisolone at doses of 1000mg/d, 500mg/d, 250mg/d, 120mg/d, 80mg/d for 3 days respectively.", + "She received intravenous immunoglobulin at 400 mg/kg/d for 5 days.", + "Her symptoms gradually improved with exception for the slowed speech.", + "Oral prednisone acetate was continued after discharge.", + "Her symptoms of slowed speech improved at 6-month follow-up." + ] + }, + { + "id": "multiclinsum_test_2075_en.txt", + "fulltext": "A 7 year-old Caucasian female was admitted to our hospital because of chest pain, cough, and fever. We learned from her medical history that, a ventriculoperitoneal shunt was placed with the diagnosis of hydrocephalus when she was 6 months old, and that the proximal part of the shunt was removed due to dysfunction two months ago but the part in the abdomen was left in its place and a new shunt was placed. During the physical examination, only crepitant rales were detected by chest auscultation. The chest roentgenogram showed an old shunt adjacent to diaphragm in left upper abdomen and a new shunt extending from in the right side . Computed tomography of thorax revealed a cavitary lesion with a diameter of 2 cm at the lower lobe of left lung, bronchiectasic areas, partial pleural thickening and a catheter end in left hemithorax .\nWe performed a left thoracotomy from 6th intercostal space and encountered a 1 cm defect in the middle of left diaphragm and the 4 cm end part of the catheter entering from this defect into thorax cavity. The borders of the defect in diaphragm were widened and the shunt was removed by eliminating the adhesions in the abdomen, and then the diaphragm was closed primarily . After 5 days of postoperative period, patient was discharged from the hospital without any clinical problem. She was remained asymptomatic for 6 months follow-up after operation.", + "fulltext_subclaims": [ + "A 7 year-old Caucasian female was admitted to our hospital because of chest pain, cough, and fever.", + "A ventriculoperitoneal shunt was placed with the diagnosis of hydrocephalus when she was 6 months old.", + "The proximal part of the shunt was removed due to dysfunction two months ago.", + "The part in the abdomen was left in its place and a new shunt was placed.", + "During the physical examination, only crepitant rales were detected by chest auscultation.", + "The chest roentgenogram showed an old shunt adjacent to diaphragm in left upper abdomen.", + "The chest roentgenogram showed a new shunt extending from in the right side.", + "Computed tomography of thorax revealed a cavitary lesion with a diameter of 2 cm at the lower lobe of left lung.", + "Computed tomography of thorax revealed bronchiectasic areas.", + "Computed tomography of thorax revealed partial pleural thickening.", + "Computed tomography of thorax revealed a catheter end in left hemithorax.", + "We performed a left thoracotomy from 6th intercostal space.", + "A 1 cm defect in the middle of left diaphragm was encountered.", + "The 4 cm end part of the catheter was entering from this defect into thorax cavity.", + "The borders of the defect in diaphragm were widened.", + "The shunt was removed by eliminating the adhesions in the abdomen.", + "The diaphragm was closed primarily.", + "After 5 days of postoperative period, patient was discharged from the hospital without any clinical problem.", + "She was remained asymptomatic for 6 months follow-up after operation." + ], + "summary": "A 7 year-old Caucasian female, hospitalized with the prediagnosis of pneumonia, was determined to have ventriculoperitoneal shunt migration at left hemithorax. A left thoracotomy was performed and the shunt was successfully removed transdiaphragmatically.", + "summary_subclaims": [ + "The patient is a 7 year-old Caucasian female.", + "The patient was hospitalized with the prediagnosis of pneumonia.", + "The patient was determined to have ventriculoperitoneal shunt migration at left hemithorax.", + "A left thoracotomy was performed.", + "The shunt was successfully removed transdiaphragmatically." + ] + }, + { + "id": "multiclinsum_test_522_en.txt", + "fulltext": "The subject of this case study was a 54-year-old male with medium build (body mass index: 21 kg/m2) who had been infected with severe acute respiratory syndrome coronavirus 2 (SARS-CoV-2) in January 2020 and diagnosed with critical COVID-19. To the best of our knowledge, the patient had enjoyed good health without any previous lung or cardiovascular conditions, except for a history of smoking for over 20 years. Symptomatic medical treatment, including antiviral treatment (umifenovir), was administered from January 29 to February 20. However, during hospitalization, the patient developed atypical pneumonia followed by ALI and severe hypoxaemia on February 12. Extracorporeal membrane oxygenation (ECMO) was initiated on February 22. The patient developed acute kidney injury requiring haemodialysis on April 1. On April 3, the patient tested negative in the SARS-CoV-2 nucleic acid test and was diagnosed to be in the recovery stage of critical-type COVID-19. Following refractory hypoxaemia after 73 days, different slices of chest computed tomography (CT) scan revealed severe pulmonary fibrosis , which was confirmed by pathological examination after lung transplantation. The patient was treated with umifenovir, convalescent plasma, alpha-interferon, corticoids, and other supporting therapy. However, there was no clinical improvement after 73 days on ECMO or active medical treatment, the patient suffered progressive dyspnoea, and progressive respiratory failure continued. In order to increase the patient’s life expectancy, double-lung transplantation was performed.\nThe patient underwent double-lung transplantation in late April 2020, following the ethical principles of international organ transplantation. The allocated lungs were harvested from the donor after brainstem death and donated through the China Organ Transplant Response System.\nExtracorporeal membrane oxygenation was discontinued 6 days after double-lung transplantation for the first time, but the patient suffered from hypoxaemia, respiratory acidosis, and circulation instability 7 days after double-lung transplantation. Hence, venous–venous ECMO was used again. In addition, biological tests showed D-dimer levels of 12.38 µg/mL, ultrasound indicated pulmonary hypertension and right heart failure, and minor levels of right pulmonary stenosis and embolism were found by CT angiography. Therefore, we administered intravenous heparin for anticoagulant therapy and inhaled nitric oxide to dilate the pulmonary arteries. The respiratory and circulation status improved during the following days. The patient was weaned from ECMO 12 days after double-lung transplantation, and tracheal intubation was removed 17 days after double-lung transplantation.\nHowever, more than 3 months after double-lung transplantation, the patient complained of progressive dyspnoea again. Branch PAS was confirmed by pulmonary artery CT angiography, which revealed stenosis in the right lower pulmonary branch, including a minor level of pulmonary embolism. Electrocardiography (ECG) results showed sinus rhythm at 79–116 b.p.m. with right bundle branch block. Echocardiography revealed right ventricular enlargement, moderate to severe tricuspid regurgitation, and an estimated right ventricular systolic pressure (RVSP) of 76 mmHg. Considering clinical presentation, ECG, echocardiography, and CT angiography findings, the patient was diagnosed with branch PAS. Later, Treprostinil injection was continuously administered for pulmonary vasodilation. However, biological tests showed that brain natriuretic peptide (BNP) and N-terminal pro-B-type natriuretic peptide (NT-proBNP) levels were not improved. The patient underwent further right cardiac catheterization examination and pulmonary angiography under general anaesthesia and mechanical ventilation. Pulmonary angiography revealed the main pulmonary artery was at a pressure of 60/20 mmHg, severe stenosis was present in the right branch pulmonary artery with a pressure of 17/9 mmHg , and mild stenosis was present in the left branch pulmonary artery with a pressure of 50/20 mmHg.\nThe MPA1 catheter (Cordis, USA) was delivered to the distal end of the right pulmonary artery after right heart catheterization and exchanged for Amplatz Super Stiff Wire (BostonScientific Corporation, USA). A 14-Fr guiding sheath (Cook Medical, Bloomington, USA) was introduced into the right pulmonary artery so as to ensure the previously preloaded 25-mm long Pul-Stent™ (Med-Zenith Company, Beijing, China) could pass through the lesion smoothly. The stent was expanded step by step with a 12-mm Balloon-in-Balloon (Numed Company, USA) after accurate location was confirmed by angiography.\nAfter the endovascular procedure, pulmonary angiography revealed the main pulmonary artery was at a pressure of 54/17 mmHg, the right branch stenotic lesion diameter improved and its estimated pressure was 45/17 mmHg , and the pressure gradient decreased from 43 to 9 mmHg. The percutaneous interventional procedure went smoothly, and the vital signs of the patient remained stable during catheterization. After treatment, echocardiography estimated the RVSP decreased from 76 to 34 mmHg. The patient’s BNP and NT-proBNP levels decreased distinctly . Additionally, the mean level of the postoperative oxygenation index was also significantly improved compared with the preoperative oxygenation index .", + "fulltext_subclaims": [ + "The subject of this case study was a 54-year-old male.", + "The patient had a body mass index of 21 kg/m2.", + "The patient had been infected with SARS-CoV-2 in January 2020.", + "The patient was diagnosed with critical COVID-19.", + "To the best of our knowledge, the patient had enjoyed good health without any previous lung or cardiovascular conditions.", + "The patient had a history of smoking for over 20 years.", + "Symptomatic medical treatment, including antiviral treatment (umifenovir), was administered from January 29 to February 20.", + "During hospitalization, the patient developed atypical pneumonia followed by ALI and severe hypoxaemia on February 12.", + "Extracorporeal membrane oxygenation (ECMO) was initiated on February 22.", + "The patient developed acute kidney injury requiring haemodialysis on April 1.", + "On April 3, the patient tested negative in the SARS-CoV-2 nucleic acid test.", + "The patient was diagnosed to be in the recovery stage of critical-type COVID-19.", + "Different slices of chest computed tomography (CT) scan revealed severe pulmonary fibrosis.", + "The patient was treated with umifenovir, convalescent plasma, alpha-interferon, corticoids, and other supporting therapy.", + "There was no clinical improvement after 73 days on ECMO or active medical treatment.", + "The patient suffered progressive dyspnoea.", + "The patient underwent double-lung transplantation in late April 2020.", + "The allocated lungs were harvested from the donor after brainstem death.", + "The lungs were donated through the China Organ Transplant Response System.", + "Extracorporeal membrane oxygenation was discontinued 6 days after double-lung transplantation for the first time.", + "The patient suffered from hypoxaemia, respiratory acidosis, and circulation instability 7 days after double-lung transplantation.", + "Venous–venous ECMO was used again.", + "Biological tests showed D-dimer levels of 12.38 µg/mL.", + "Ultrasound indicated pulmonary hypertension and right heart failure.", + "Minor levels of right pulmonary stenosis and embolism were found by CT angiography.", + "Intravenous heparin was administered for anticoagulant therapy.", + "Inhaled nitric oxide was administered to dilate the pulmonary arteries.", + "The respiratory and circulation status improved during the following days.", + "The patient was weaned from ECMO 12 days after double-lung transplantation.", + "Tracheal intubation was removed 17 days after double-lung transplantation.", + "More than 3 months after double-lung transplantation, the patient complained of progressive dyspnoea again.", + "Branch PAS was confirmed by pulmonary artery CT angiography.", + "The CT angiography revealed stenosis in the right lower pulmonary branch, including a minor level of pulmonary embolism.", + "Electrocardiography (ECG) results showed sinus rhythm at 79–116 b.p.m. with right bundle branch block.", + "Echocardiography revealed right ventricular enlargement, moderate to severe tricuspid regurgitation, and an estimated right ventricular systolic pressure (RVSP) of 76 mmHg.", + "The patient was diagnosed with branch PAS.", + "Treprostinil injection was continuously administered for pulmonary vasodilation.", + "Biological tests showed that brain natriuretic peptide (BNP) and N-terminal pro-B-type natriuretic peptide (NT-proBNP) levels were not improved.", + "The patient underwent further right cardiac catheterization examination and pulmonary angiography under general anaesthesia and mechanical ventilation.", + "Pulmonary angiography revealed the main pulmonary artery was at a pressure of 60/20 mmHg.", + "Severe stenosis was present in the right branch pulmonary artery with a pressure of 17/9 mmHg.", + "Mild stenosis was present in the left branch pulmonary artery with a pressure of 50/20 mmHg.", + "The MPA1 catheter was delivered to the distal end of the right pulmonary artery after right heart catheterization.", + "The catheter was exchanged for Amplatz Super Stiff Wire.", + "A 14-Fr guiding sheath was introduced into the right pulmonary artery.", + "A 25-mm long Pul-Stent™ was preloaded.", + "The stent was expanded step by step with a 12-mm Balloon-in-Balloon after accurate location was confirmed by angiography.", + "After the endovascular procedure, pulmonary angiography revealed the main pulmonary artery was at a pressure of 54/17 mmHg.", + "The right branch stenotic lesion diameter improved and its estimated pressure was 45/17 mmHg.", + "The pressure gradient decreased from 43 to 9 mmHg.", + "The percutaneous interventional procedure went smoothly.", + "The vital signs of the patient remained stable during catheterization.", + "After treatment, echocardiography estimated the RVSP decreased from 76 to 34 mmHg.", + "The patient’s BNP and NT-proBNP levels decreased distinctly.", + "The mean level of the postoperative oxygenation index was also significantly improved compared with the preoperative oxygenation index." + ], + "summary": "The subject was a 54-year-old male with severe acute respiratory syndrome coronavirus 2 infection who underwent a double-lung transplantation. He suffered hypoxaemia and right heart dysfunction following the operation. Right cardiac catheterization and pulmonary angiography examination revealed severe stenosis of the right branch pulmonary artery. Due to immunosuppression and reduced coagulation function, the patient underwent pulmonary artery balloon dilatation and stent implantation, and ultimately recovered well.", + "summary_subclaims": [ + "The subject was a 54-year-old male with severe acute respiratory syndrome coronavirus 2 infection who underwent a double-lung transplantation.", + "He suffered hypoxaemia and right heart dysfunction following the operation.", + "Right cardiac catheterization and pulmonary angiography examination revealed severe stenosis of the right branch pulmonary artery.", + "Due to immunosuppression and reduced coagulation function, the patient underwent pulmonary artery balloon dilatation and stent implantation.", + "The patient ultimately recovered well." + ] + }, + { + "id": "multiclinsum_test_1720_en.txt", + "fulltext": "A 61-year-old Japanese man had a cervical spinal cord injury approximately 2 years previously, and underwent cervical laminoplasty from C4 to C7 at a different hospital. Preoperative magnetic resonance imaging (MRI) revealed spinal canal stenosis at C5/6 and C6/7, and MRI after laminoplasty revealed decompression of the spinal cord . He was referred to our hospital 6 months after surgery because of progressively worsening spasticity of the lower limbs. We performed ITB pump (SynchroMed II, Medtronic, Inc., Minneapolis, MN, USA) implantation by inserting an intrathecal catheter through the L2/3 interlaminar space to the T8/9 level . After surgery, his spastic gait improved and progressed well; however, 1 year after surgery, intermittent claudication was observed, making it difficult for the patient to walk long distances. Physical examination revealed numbness and mild muscle weakness in both lower extremities. No signs of spinal tension were observed. MRI of the lumbar spine revealed multiple LSS at L1/2, L2/3, L3/4, and L4/5 . Based on these findings, we planned to decompress all stenotic areas. We also considered the possibility that the intrathecal catheter inserted through the L2/3 interlaminar space would need to be removed in preparation for surgery.", + "fulltext_subclaims": [ + "The patient is a 61-year-old Japanese man.", + "He had a cervical spinal cord injury approximately 2 years previously.", + "He underwent cervical laminoplasty from C4 to C7 at a different hospital.", + "Preoperative MRI revealed spinal canal stenosis at C5/6 and C6/7.", + "MRI after laminoplasty revealed decompression of the spinal cord.", + "He was referred to our hospital 6 months after surgery.", + "He had progressively worsening spasticity of the lower limbs.", + "We performed ITB pump (SynchroMed II, Medtronic, Inc.) implantation.", + "An intrathecal catheter was inserted through the L2/3 interlaminar space to the T8/9 level.", + "After surgery, his spastic gait improved and progressed well.", + "One year after surgery, intermittent claudication was observed.", + "Intermittent claudication made it difficult for the patient to walk long distances.", + "Physical examination revealed numbness and mild muscle weakness in both lower extremities.", + "No signs of spinal tension were observed.", + "MRI of the lumbar spine revealed multiple LSS at L1/2, L2/3, L3/4, and L4/5.", + "We planned to decompress all stenotic areas.", + "We considered the possibility that the intrathecal catheter inserted through the L2/3 interlaminar space would need to be removed in preparation for surgery." + ], + "summary": "We report the case of a 61-year-old Japanese man with lumbar spinal stenosis who underwent intrathecal baclofen therapy. We performed decompression for lumbar spinal stenosis at the intrathecal catheter insertion site during intrathecal baclofen therapy. The yellow ligament was removed by partial resection of the lamina under a microscope to avoid damage to the intrathecal catheter. The dura mater was distended. No obvious cerebrospinal fluid leakage was observed. Postoperatively, lumbar spinal stenosis symptoms improved, and spasticity remained well controlled with intrathecal baclofen therapy.", + "summary_subclaims": [ + "The patient was a 61-year-old Japanese man.", + "The patient had lumbar spinal stenosis.", + "The patient underwent intrathecal baclofen therapy.", + "Decompression for lumbar spinal stenosis was performed at the intrathecal catheter insertion site during intrathecal baclofen therapy.", + "The yellow ligament was removed by partial resection of the lamina.", + "The removal was performed under a microscope.", + "The removal was done to avoid damage to the intrathecal catheter.", + "The dura mater was distended.", + "No obvious cerebrospinal fluid leakage was observed.", + "Lumbar spinal stenosis symptoms improved postoperatively.", + "Spasticity remained well controlled with intrathecal baclofen therapy." + ] + }, + { + "id": "multiclinsum_test_397_en.txt", + "fulltext": "A 34-year-old Japanese man, with no significant previous medical history, presented to our hospital because of an incidentally detected renal tumor. The patient did not have a family history of RCC or any signs of hereditary RCC syndrome on examination. He did not have any physical and laboratory findings indicating RCC including microscopic hematuria. Contrast enhanced computed tomography (CT) confirmed a 2.5 cm left kidney tumor; it showed the early enhancement and washout typical of a clear cell RCC. Additionally, a retroperitoneal tumor with calcification was identified, the presence of lipid and soft tissue components was confirmed, and a presumptive diagnosis of retroperitoneal liposarcoma was made . Abdominal magnetic resonance imaging (MRI) showed a tumor located in the interaortocaval space with high signal intensity on the T2-weighted images. No apparent metastases were identified.Left partial nephrectomy and resection of the retroperitoneal tumor were performed in September 2003. The pathological diagnoses were clear cell renal carcinoma and retroperitoneal liposarcoma . The excised retroperitoneal tumor was a 6.8 × 4.8 cm well-circumscribed mass. Cut sections of the tumor had a lobulated yellowish appearance. Histological examination revealed the tumor to be composed of a mixture of fibrous tissue and mature-appearing adipose tissues , with the fibrous tissue separation the adipose tissue into regions of varied size. The adipose cells appeared almost mature, but the tumor contained atypical cells with varied size and shape, including a few mono- or mutli-vacuolated lipoblastic cells. The fibrous tissues contained muscle fibers. Few cells were positive for MIB-1 antibody (proliferating cells). The resected renal tumor was 1.6 × 1.6 cm in size, histopathology showed a clear cell RCC circumscribed by a fibrous capsule, classified as G1 pT1a (i.e. less than 4 cm in size and confined to the kidney). Surgical margins of both tumors were negative and no adjuvant treatment was performed. Ten years after the operation, the patient is doing well and has not experienced a recurrence.\nYoung patient age can indicate a hereditary RCC syndrome. However, our patient had no family history and clinical signs of tuberous sclerosis, von Hippel-Lindau disease, and succinate dehydrogenase-associated familial cancer.\nWe identified five reported cases of concurrent liposarcoma and RCC [–] . Patients age ranged from 58 to 79 years (median 71 years), slightly older than the average age for all RCC patients. The RCC histological subtype was clear cell in 1 case , papillary cell in 3 cases [, , ] and granular cell in 1 case (note: it has recently been shown that “granular cell” type RCC is not an independent histological type). The location of liposarcoma was perirenal [, ] in 2 cases, retroperitoneal [, ] in 2 cases, and cardiac in 1 case (found by autopsy). Although the number of reported cases is small, it is interesting to note that only one case represented the clear cell subtype whereas three cases were diagnosed as papillary cell RCC. In the present case retroperitoneal liposarcoma was located in interaortocaval space and RCC histology was clear cell. Our case and all of the previously reported cases were males, which fits with the male predisposition for RCC.\nIn addition to the previously described cases, we found two published case reports regarding liposarcomatous differentiation in chromophobe RCCs [, ]. In contrast, the renal tumor in our case was a typical clear cell RCC, and the two tumors represented distinct entities.\nOver the last 15 years, 1123 patients with retroperitoneal soft tissue sarcoma have been reported in 25 series; these tumors had a mean diameter of 15.7 cm . Retroperitoneal soft tissue sarcomas represent 0.10 to 0.15% of all malignancies and 45% of all retroperitoneal tumors. Because of the localization, symptoms are nonspecific (e.g., abdominal discomfort and palpable mass) and caused by tumor growth, which is typically very large when detected. The only curative treatment modality is complete surgical resection; chemotherapy and radiation therapy show no survival benefit. It has been reported that 51.4% of these tumors can be completely excised and that 50.2% of these excisions include adjacent organs . The prognosis without complete excision is poor with reported 5- and 10-year survival rates of 16.7% and 8.0% respectively .\nLocal recurrence represents the major type of progression for retroperitoneal liposarcomas. Yamamoto et al. described 45 patients with well-differentiated liposarcoma who underwent surgical treatment. Among 41 patients who underwent initial surgery, only one recurrence occurred, which was localized in the retroperitoneal space. For 4 patients who underwent a reoperation, the mean time between the initial surgery and the recurrence was 16.5 years. None of the 45 patients developed distant metastasis. In our case, during the 10 years of follow-up to date, no recurrence or metastasis has been detected. However, continued follow-up is necessary because late recurrences are common with liposarcoma.\nPreviously reported liposarcomas have demonstrated heterogeneous signal intensity on MRI with great variation depending on the components and histological patterns of a particular tumor. Retroperitoneal liposarcomas have been classified into several clinico-pathological subtypes . Myxoid liposarcoma, consisting of a myxoid matrix and a small amount of mature fat, shows low signal intensity on T1 weighted image and high signal intensity on T2 weighted image . Well-differentiated liposarcoma presented high signal intensity on T1 weighted images, intermediate signal intensity on T2 weighted images, drop-out signal intensity on fat-suppressed MR images . Round-cell liposarcoma and pleomorphic liposarcoma exhibit the signal intensity of a soft-tissue tumor without a characteristic fat signal . Liposarcomas can present with intratumoral hemorrhage and may invade adjacent organs. In the present case, the tumor showed high signal intensity on the T2-weighted images, which is typical for myxoid liposarcoma and is inconsistent with well-differentiated liposarcoma which was diagnosed pathologically. Five-year and ten-year disease specific survival is the highest for well-differentiated liposarcoma (100% and 87%) followed by myxoid liposarcoma (88% and 76%), and is the lowest for pleomorphic liposarcoma (56% and 39%) .", + "fulltext_subclaims": [ + "The patient is a 34-year-old Japanese man.", + "The patient had no significant previous medical history.", + "The patient did not have a family history of RCC.", + "The patient did not have signs of hereditary RCC syndrome.", + "Contrast enhanced CT confirmed a 2.5 cm left kidney tumor.", + "The tumor showed early enhancement and washout typical of clear cell RCC.", + "A retroperitoneal tumor with calcification was identified.", + "The presence of lipid and soft tissue components was confirmed.", + "A presumptive diagnosis of retroperitoneal liposarcoma was made.", + "Abdominal MRI showed a tumor located in the interaortocaval space.", + "The tumor showed high signal intensity on T2-weighted images.", + "No apparent metastases were identified.", + "Left partial nephrectomy and resection of the retroperitoneal tumor were performed in September 2003.", + "The excised retroperitoneal tumor was 6.8 × 4.8 cm in size.", + "Cut sections of the tumor had a lobulated yellowish appearance.", + "Histological examination revealed the tumor to be composed of a mixture of fibrous tissue and mature-appearing adipose tissues.", + "The fibrous tissue separated the adipose tissue into regions of varied size.", + "The adipose cells appeared almost mature.", + "The tumor contained atypical cells with varied size and shape.", + "The tumor contained a few mono- or multi-vacuolated lipoblastic cells.", + "The fibrous tissues contained muscle fibers.", + "Few cells were positive for MIB-1 antibody.", + "The resected renal tumor was 1.6 × 1.6 cm in size.", + "Histopathology showed clear cell RCC circumscribed by a fibrous capsule.", + "The tumor was classified as G1 pT1a.", + "Surgical margins of both tumors were negative.", + "No adjuvant treatment was performed.", + "Ten years after the operation, the patient is doing well.", + "The patient has not experienced a recurrence.", + "Young patient age can indicate a hereditary RCC syndrome.", + "Our patient had no family history and clinical signs of tuberous sclerosis.", + "Our patient had no clinical signs of von Hippel-Lindau disease.", + "Our patient had no clinical signs of succinate dehydrogenase-associated familial cancer.", + "We identified five reported cases of concurrent liposarcoma and RCC.", + "Patients' age ranged from 58 to 79 years.", + "The median age of the reported cases was 71 years.", + "The RCC histological subtype was clear cell in 1 case.", + "The RCC histological subtype was papillary cell in 3 cases.", + "The RCC histological subtype was granular cell in 1 case.", + "The granular cell type RCC is not an independent histological type.", + "The location of liposarcoma was perirenal in 2 cases.", + "The location of liposarcoma was retroperitoneal in 2 cases.", + "The location of liposarcoma was cardiac in 1 case.", + "Only one case represented the clear cell subtype.", + "Three cases were diagnosed as papillary cell RCC.", + "In the present case, retroperitoneal liposarcoma was located in the interaortocaval space.", + "In the present case, RCC histology was clear cell.", + "All of the previously reported cases were males.", + "Our case and all of the previously reported cases were males.", + "We found two published case reports regarding liposarcomatous differentiation in chromophobe RCCs.", + "The renal tumor in our case was a typical clear cell RCC.", + "The two tumors represented distinct entities.", + "Over the last 15 years, 1123 patients with retroperitoneal soft tissue sarcoma have been reported in 25 series.", + "These tumors had a mean diameter of 15.7 cm.", + "Retroperitoneal soft tissue sarcomas represent 0.10 to 0.15% of all malignancies.", + "Retroperitoneal soft tissue sarcomas represent 45% of all retroperitoneal tumors.", + "Symptoms are nonspecific and caused by tumor growth.", + "The only curative treatment modality is complete surgical resection.", + "Chemotherapy and radiation therapy show no survival benefit.", + "51.4% of these tumors can be completely excised.", + "50.2% of these excisions include adjacent organs.", + "The prognosis without complete excision is poor.", + "Reported 5- and 10-year survival rates are 16.7% and 8.0% respectively.", + "Local recurrence represents the major type of progression for retroperitoneal liposarcomas.", + "Yamamoto et al. described 45 patients with well-differentiated liposarcoma who underwent surgical treatment.", + "Among 41 patients who underwent initial surgery, only one recurrence occurred.", + "The recurrence was localized in the retroperitoneal space.", + "For 4 patients who underwent a reoperation, the mean time between the initial surgery and the recurrence was 16.5 years.", + "None of the 45 patients developed distant metastasis.", + "In our case, during the 10 years of follow-up to date, no recurrence or metastasis has been detected.", + "Continued follow-up is necessary because late recurrences are common with liposarcoma.", + "Previously reported liposarcomas have demonstrated heterogeneous signal intensity on MRI.", + "Myxoid liposarcoma shows low signal intensity on T1-weighted images.", + "Myxoid liposarcoma shows high signal intensity on T2-weighted images.", + "Well-differentiated liposarcoma presented high signal intensity on T1-weighted images.", + "Well-differentiated liposarcoma presented intermediate signal intensity on T2-weighted images.", + "Well-differentiated liposarcoma showed drop-out signal intensity on fat-suppressed MR images.", + "Round-cell liposarcoma and pleomorphic liposarcoma exhibit the signal intensity of a soft-tissue tumor without a characteristic fat signal.", + "Liposarcomas can present with intratumoral hemorrhage.", + "Liposarcomas may invade adjacent organs.", + "In the present case, the tumor showed high signal intensity on the T2-weighted images.", + "The tumor signal intensity is typical for myxoid liposarcoma.", + "The tumor signal intensity is inconsistent with well-differentiated liposarcoma.", + "Five-year and ten-year disease specific survival is the highest for well-differentiated liposarcoma.", + "Five-year and ten-year disease specific survival is 100% and 87% for well-differentiated liposarcoma.", + "Five-year and ten-year disease specific survival is 88% and 76% for myxoid liposarcoma.", + "Five-year and ten-year disease specific survival is the lowest for pleomorphic liposarcoma.", + "Five-year and ten-year disease specific survival is 56% and 39% for pleomorphic liposarcoma." + ], + "summary": "Concurrent retroperitoneal liposarcoma and renal cell carcinoma were found in a 34-year-old Japanese man. The renal tumor was first detected by ultrasonography, it was confirmed by computed tomography, which also identified a presumptive retroperitoneal liposarcoma, and the tumors were further assessed with magnetic resonance imaging. The patient was treated by surgical resection of retroperitoneal liposarcoma and left nephrectomy and has been disease-free for 10 years.", + "summary_subclaims": [ + "Concurrent retroperitoneal liposarcoma and renal cell carcinoma were found in a 34-year-old Japanese man.", + "The renal tumor was first detected by ultrasonography.", + "The renal tumor was confirmed by computed tomography.", + "Computed tomography identified a presumptive retroperitoneal liposarcoma.", + "The tumors were further assessed with magnetic resonance imaging.", + "The patient was treated by surgical resection of retroperitoneal liposarcoma.", + "The patient was treated by left nephrectomy.", + "The patient has been disease-free for 10 years." + ] + }, + { + "id": "multiclinsum_test_1297_en.txt", + "fulltext": "A 68-year-old woman was referred to our hospital on December 2011, due to right upper quadrant pain and a 5-pound weight loss.\nOther symptoms were not presented and she did not drink alcohol, smoke or have a history of surgery.\nPhysical examination revealed a soft abdomen, no tenderness, no rebound tenderness, and no palpable lymph nodes or abdominal mass.\nThe following laboratory data were recorded: hemoglobin of 125 g/L; white cell count of 5.5 × 109/L, with 72.5% neutrophils; platelet count of 234 × 109 L; alanine aminotransferase of 25 U/L; serum total protein of 75 g/L; albumin of 37.2 g/L; total bilirubin of 11 μmol/L; direct bilirubin of 9.5 μmol/L; α-fetoprotein of 5.23 ng/mL; and carcinoembryonic antigen of 4.5 ng/L. Serological markers for hepatitis B virus and HCV were negative. The indocyanine green retention rate at 15 min was 2.2%.\nAbdominal ultrasonography showed there was a mixed echoic mass measuring around 10 cm × 7 cm in the right hepatic lobe. Abdominal computed tomography (CT) showed a similar finding, that the tumor was inhomogeneous density, with mild delayed enhancement, and had central necrosis . Gastrointestinal endoscopy and colonoscopy showed negative findings. Chest CT showed no mass over the lung.\nPreoperative diagnosis was unconfirmed, exploratory laparotomy was performed 1 wk after admission, and no obvious effusion was found in the abdominal cavity. The entire liver VIII was occupied by a creamy white, firm mass measuring about 10 cm × 7 cm, which protruded into the abdominal cavity and appeared to invade the diaphragm and middle hepatic vein , making the tumor unresectable ; thus, a biopsy was performed. Rapid frozen-section biopsy analysis considered the diagnosis of leiomyosarcoma. Histopathological examination showed a hepatic mass that consisted of spindle-shaped cells with mitotic figures and nuclear atypia . Immunohistochemical staining showed that spindle-shaped cells were positive for anti-smooth muscle actin and desmin but negative for keratin, S-100, CD34 and CD117. No obvious lesions were observed in the bilateral adnexa and uterus, and no palpable mass was detected in the superficial body.", + "fulltext_subclaims": [ + "A 68-year-old woman was referred to our hospital on December 2011 due to right upper quadrant pain and a 5-pound weight loss.", + "Other symptoms were not presented.", + "She did not drink alcohol.", + "She did not smoke.", + "She did not have a history of surgery.", + "Physical examination revealed a soft abdomen.", + "There was no tenderness.", + "There was no rebound tenderness.", + "No palpable lymph nodes were found.", + "No abdominal mass was palpable.", + "Hemoglobin was 125 g/L.", + "White cell count was 5.5 × 109/L.", + "Neutrophils were 72.5%.", + "Platelet count was 234 × 109/L.", + "Alanine aminotransferase was 25 U/L.", + "Serum total protein was 75 g/L.", + "Albumin was 37.2 g/L.", + "Total bilirubin was 11 μmol/L.", + "Direct bilirubin was 9.5 μmol/L.", + "α-fetoprotein was 5.23 ng/mL.", + "Carcinoembryonic antigen was 4.5 ng/L.", + "Serological markers for hepatitis B virus were negative.", + "Serological markers for HCV were negative.", + "The indocyanine green retention rate at 15 min was 2.2%.", + "Abdominal ultrasonography showed a mixed echoic mass measuring around 10 cm × 7 cm in the right hepatic lobe.", + "Abdominal CT showed the tumor was inhomogeneous density.", + "The tumor had mild delayed enhancement.", + "The tumor had central necrosis.", + "Gastrointestinal endoscopy showed negative findings.", + "Colonoscopy showed negative findings.", + "Chest CT showed no mass over the lung.", + "Preoperative diagnosis was unconfirmed.", + "Exploratory laparotomy was performed 1 wk after admission.", + "No obvious effusion was found in the abdominal cavity.", + "The entire liver VIII was occupied by a creamy white, firm mass measuring about 10 cm × 7 cm.", + "The tumor protruded into the abdominal cavity.", + "The tumor appeared to invade the diaphragm.", + "The tumor appeared to invade the middle hepatic vein.", + "The tumor was considered unresectable.", + "A biopsy was performed.", + "Rapid frozen-section biopsy analysis considered the diagnosis of leiomyosarcoma.", + "Histopathological examination showed a hepatic mass that consisted of spindle-shaped cells with mitotic figures and nuclear atypia.", + "Immunohistochemical staining showed that spindle-shaped cells were positive for anti-smooth muscle actin.", + "Immunohistochemical staining showed that spindle-shaped cells were positive for desmin.", + "Immunohistochemical staining showed that spindle-shaped cells were negative for keratin.", + "Immunohistochemical staining showed that spindle-shaped cells were negative for S-100.", + "Immunohistochemical staining showed that spindle-shaped cells were negative for CD34.", + "Immunohistochemical staining showed that spindle-shaped cells were negative for CD117.", + "No obvious lesions were observed in the bilateral adnexa and uterus.", + "No palpable mass was detected in the superficial body." + ], + "summary": "We describe here the first case of primary hepatic leiomyosarcoma successfully treated by transcatheter arterial chemoembolization (TACE). The patient was a 68-year-old woman who presented with right upper quadrant pain and weight loss over the past 5 wk before admission. Abdominal computed tomography (commonly known as CT) and ultrasonography showed a mixed echoic mass measuring about 10 cm × 7 cm occupying the right lobe of the liver. Exploratory laparotomy was performed 1 wk after admission. The tumor was unresectable and biopsy was performed. Based on rapid frozen-section and histopathological examination, a final diagnosis of primary hepatic leiomyosarcoma was established. TACE was performed 2 wk later. The postoperative course was uneventful and the patient was discharged on day 7 after the operation. Contrast-enhanced CT showed that the tumor significantly shrunk with satisfactory lipiodol deposition. The patient has been followed up for 82 mo until now, and no progressive enlargement of the tumor or distal metastasis was observed.", + "summary_subclaims": [ + "This is the first case of primary hepatic leiomyosarcoma successfully treated by transcatheter arterial chemoembolization.", + "The patient was a 68-year-old woman.", + "She presented with right upper quadrant pain and weight loss over the past 5 wk before admission.", + "Abdominal CT and ultrasonography showed a mixed echoic mass measuring about 10 cm × 7 cm occupying the right lobe of the liver.", + "Exploratory laparotomy was performed 1 wk after admission.", + "The tumor was unresectable.", + "A biopsy was performed.", + "A final diagnosis of primary hepatic leiomyosarcoma was established.", + "TACE was performed 2 wk later.", + "The postoperative course was uneventful.", + "The patient was discharged on day 7 after the operation.", + "Contrast-enhanced CT showed that the tumor significantly shrunk with satisfactory lipiodol deposition.", + "The patient has been followed up for 82 mo until now.", + "No progressive enlargement of the tumor was observed.", + "No distal metastasis was observed." + ] + }, + { + "id": "multiclinsum_test_1309_en.txt", + "fulltext": "A 59-year-old caucasian female was diagnosed with thyroid papillary carcinoma after total thyroidectomy in 2001. Diagnosed with postsurgical hypothyroidism under treatment with levothyroxine, 100 micrograms per day. There was no other previous medical history of interest. The patient did not consume tobacco or alcohol.\nIn 2008, a computerized tomography scan (CT) showed locoregional relapse and surgery was performed with resection of locoregional recurrence and left cervical lymphadenectomy. In November 2011, pulmonary relapse was treated with I-131 since November 2011 until March 2012 (total accumulated dose: 850 mCi). In October 2016, a CT scan showed a progression of the disease with cervical and pulmonary progression. The patient started sorafenib, 400 mg twice a day. Stable disease was maintained during 20 months. In June 2018, patient presented an episode of abrupt instability and cervical pain. The magnetic resonance imaging (MRI) showed a new metastatic lesion in the skull base with destruction of bony structures of the left occipital-petrous region. At this point, a molecular study of the cervical node was performed and a mutation in BRAF was found.\nDue to the lack of alternative therapeutic options, treatment with vemurafenib–trametinib was requested as a compassionate use. In August 2018, patient was started on the combination of dabrafenib 150 mg twice a day and trametinib 2 mg once a day. MRI in October 2018 showed a slight decrease of the metastatic lesion in the skull base . In addition, the patient showed evident clinical improvement with decreased initial headache and cervicalgia.\nA follow-up PET–CT scan was performed in January 2019. Tumor was on radiological partial response. In addition, there was intestinal pneumatosis with mild sign of pneumoperitoneum . Patient had no digestive symptoms and the abdominal medical examination was completely normal. Also normal neurological examination was verified. Routine physical examination showed blood pressure 110/60 mmHg, heart rate 80 bpm and 36.5 degree centigrade temperature. Blood test showed normal liver function: AST 21 U/L, ALT 16 U/L, bilirubin 0.19 mg/dL and normal renal function: creatinine 0.7 and glomerular filtrate > 90 mL/min. Blood count values were normal: leukocytes 7.6 × 1000/µL, hemoglobin 12 g/dL and platelets 417 × 1000/µL.\nThe surgery department recommended conservative treatment unless new abdominal signs or symptoms were seen. Intravenous metoclopramide 10 mg/8 h and paracetamol 1000 mg/8 h were administrated. Both drugs, dabrafenib and trametinib, were discontinued after the PI diagnosis.\nOnly 10 days after the discontinuation of targeted therapy, tumor progression was shown with clinical deterioration due to intracranial hypertension and the patient died 4 weeks later because of intracranial disease progression. Because the cause of death was related with tumor progression, autopsy was not performed.", + "fulltext_subclaims": [ + "A 59-year-old caucasian female was diagnosed with thyroid papillary carcinoma after total thyroidectomy in 2001.", + "She was diagnosed with postsurgical hypothyroidism under treatment with levothyroxine, 100 micrograms per day.", + "There was no other previous medical history of interest.", + "The patient did not consume tobacco or alcohol.", + "In 2008, a computerized tomography scan (CT) showed locoregional relapse and surgery was performed with resection of locoregional recurrence and left cervical lymphadenectomy.", + "In November 2011, pulmonary relapse was treated with I-131 since November 2011 until March 2012 (total accumulated dose: 850 mCi).", + "In October 2016, a CT scan showed a progression of the disease with cervical and pulmonary progression.", + "The patient started sorafenib, 400 mg twice a day.", + "Stable disease was maintained during 20 months.", + "In June 2018, patient presented an episode of abrupt instability and cervical pain.", + "The magnetic resonance imaging (MRI) showed a new metastatic lesion in the skull base with destruction of bony structures of the left occipital-petrous region.", + "A molecular study of the cervical node was performed and a mutation in BRAF was found.", + "Due to the lack of alternative therapeutic options, treatment with vemurafenib–trametinib was requested as a compassionate use.", + "In August 2018, patient was started on the combination of dabrafenib 150 mg twice a day and trametinib 2 mg once a day.", + "MRI in October 2018 showed a slight decrease of the metastatic lesion in the skull base.", + "The patient showed evident clinical improvement with decreased initial headache and cervicalgia.", + "A follow-up PET–CT scan was performed in January 2019.", + "Tumor was on radiological partial response.", + "There was intestinal pneumatosis with mild sign of pneumoperitoneum.", + "Patient had no digestive symptoms and the abdominal medical examination was completely normal.", + "Also normal neurological examination was verified.", + "Routine physical examination showed blood pressure 110/60 mmHg, heart rate 80 bpm and 36.5 degree centigrade temperature.", + "Blood test showed normal liver function: AST 21 U/L, ALT 16 U/L, bilirubin 0.19 mg/dL and normal renal function: creatinine 0.7 and glomerular filtrate > 90 mL/min.", + "Blood count values were normal: leukocytes 7.6 × 1000/µL, hemoglobin 12 g/dL and platelets 417 × 1000/µL.", + "The surgery department recommended conservative treatment unless new abdominal signs or symptoms were seen.", + "Intravenous metoclopramide 10 mg/8 h and paracetamol 1000 mg/8 h were administrated.", + "Both drugs, dabrafenib and trametinib, were discontinued after the PI diagnosis.", + "Only 10 days after the discontinuation of targeted therapy, tumor progression was shown with clinical deterioration due to intracranial hypertension.", + "The patient died 4 weeks later because of intracranial disease progression.", + "Because the cause of death was related with tumor progression, autopsy was not performed." + ], + "summary": "A 59-year-old caucasian female with radioactive iodine-refractory metastatic thyroid papillary carcinoma with BRAFV600E mutation was treated with dabrafenib and trametinib as a compassionate use. After 4 months treatment, positron emission tomography-computed tomography (PET-CT) showed PI. At the time of diagnosis, the patient was asymptomatic without signs of peritonitis. The initial treatment was conservative and no specific treatment for PI was needed. Unfortunately, after dabrafenib-trametinib withdrawal, the patient developed tumor progression with significant clinical worsening.", + "summary_subclaims": [ + "The patient is a 59-year-old caucasian female.", + "She has radioactive iodine-refractory metastatic thyroid papillary carcinoma.", + "She has a BRAFV600E mutation.", + "She was treated with dabrafenib and trametinib as a compassionate use.", + "After 4 months of treatment, PET-CT showed PI.", + "At the time of diagnosis, the patient was asymptomatic.", + "She had no signs of peritonitis.", + "The initial treatment was conservative.", + "No specific treatment for PI was needed.", + "After dabrafenib-trametinib withdrawal, the patient developed tumor progression.", + "She had significant clinical worsening." + ] + }, + { + "id": "multiclinsum_test_3367_en.txt", + "fulltext": "A 56-year-old Caucasian male presented with a diagnosis of recurrent heart failure. Previously, he was given a diagnosis of palindromic rheumatism based on a four-year history of lower extremity migratory joint pain and swelling that failed to respond to NSAIDs and hydroxychloroquine. During this time, he also developed unintentional weight loss, fatigue and cognitive impairment. Past medical history was significant for a renal cell carcinoma, treated with a left nephrectomy 4 years prior to presentation. The patient had a 45-pack year smoking history. He had not travelled abroad except for New Zealand and Hawaii 25 years ago.\n\nThe patient had been previously evaluated over 4 years by numerous services including rheumatology, hematology, cardiology and dermatology with an extensive work-up, including blood cultures that were negative on repeat occasions. Eleven months prior to current presentation, the patient developed recurrent acute congestive heart failure exacerbation, requiring multiple admissions with treatment involving diuretics and chest tubes, providing limited short-term symptomatic relief.\n\nOn this presentation, the patient had symptoms consistent with an exacerbation of congestive heart failure. The patient stated he had lost approximately 40 pounds over 6 months. He denied any GI symptoms, fevers, chills or night sweats. Physical examination revealed the patient as pale, afebrile and hemodynamically stable. He was noted to be cachectic with a weight of fifty-one kilograms (BMI: 17.8). Pitting edema of both lower extremities to the proximal shin with hyperpigmentation was noted. As observed on the initial CT scan, there was diffuse lymphadenopathy and right epitrochlear lymphadenopathy in particular was noted. Jugular venous distension was noted to 8 cm above the sternal angle with a positive Kussmaul’s sign on inspiration. The patient had a 3/6 systolic ejection murder without a pericardial knock. There was no oculomasticatory myorhythmia or supranuculear vertical gaze palsy observed.\n\nTransthoracic echocardiogram imaging was reviewed from 2014 to the 2016. In 2014, subtle tethering of the mitral valve was noted with thickening and cord calcification. The posterior leaflet had reduced excursion and the mitral valve apparatus was apically displaced. There was the observation of subtle diastolic doming over the anterior mitral leaflet. Progressive echocardiogram findings in 2016 showed the anterior mitral valve to be thickened with reduced excursion, the posterior leaflet to be fixed and cords with shortening. Overall, this was in keeping with pseudoprolapse. Over the aortic valve, there was systolic doming of the right coronary cusp and calcification from the commissural aspect of the aortic valve with sparing of the base. Notably, there was the presence septal shuttering in early diastole with early inspiratory septal bounce/shift, indicative of abnormal heart and lung interaction. Overall, this was suggestive of early constrictive physiology.\n\nA repeat transthoracic echocardiogram on admission showed numerous interval changes including; a reduction in left ventricle systolic function (ejection fraction of 48%), severe mitral regurgitation, moderate tricuspid regurgitation, moderate aortic regurgitation and worsening pulmonary hypertension (RSVP 78 mmHg). Calcific aortic valve changes were noted that were felt to be post-inflammatory as opposed to degenerative changes. The mitral valve had an unusual appearance suggestive of prior valvulitis, in particular rheumatic in nature. The pericardium was thickened with features of exaggerated heart and lung interactions, consistent with constrictive physiology. Based on these findings, pericardial stripping and valvular surgery were proposed.\n\nPerioperative findings consisted of thick pericardium and densely adherent to the surrounding anatomy. The mitral valve was grossly abnormal with fibrosis, in keeping with a rheumatic type process and was subsequently replaced with a bioprosthetic valve. The tricuspid valve had thickened leaflets with slightly thickened papillary muscle and was repaired with a ring annuloplasty. The thickened aortic valve was addressed with primary repair.\n\nThe above constellation of symptoms, in the context with prior work-up as unremarkable, lent to a strong clinical suspicion of an atypical presentation of Whipple’s disease. Two days post-op, duodenal biopsies were obtained, and surprisingly were not consistent with Whipple’s disease. On the request of the clinician, the cardiac valves and pericardium pathology specimens were examined for PAS staining and PCR. The cardiac specimens demonstrated numerous foamy macrophages filled with PAS positive material compatible with Whipple’s disease. Tropheryma whipplei was identified by direct 16S rDNA PCR on the mitral valve with > 99% sequence match. The pathological changes were consistent with active endocarditis, myocarditis, and pericarditis, caused by T. whipplei. The patient started treatment with IV Penicillin G for 14 days and subsequently maintained regimen of oral sulfamethoxazole-trimethoprim for long-term treatment. Six months following diagnosis, the patient has had no complications and is clinically improving.", + "fulltext_subclaims": [ + "The patient is a 56-year-old Caucasian male.", + "He presented with a diagnosis of recurrent heart failure.", + "Previously, he was given a diagnosis of palindromic rheumatism.", + "He had a four-year history of lower extremity migratory joint pain and swelling.", + "The joint pain and swelling failed to respond to NSAIDs and hydroxychloroquine.", + "He developed unintentional weight loss.", + "He had fatigue.", + "He had cognitive impairment.", + "Past medical history was significant for a renal cell carcinoma.", + "The renal cell carcinoma was treated with a left nephrectomy.", + "The left nephrectomy occurred 4 years prior to presentation.", + "He had a 45-pack year smoking history.", + "He had not travelled abroad except for New Zealand and Hawaii 25 years ago.", + "He had been previously evaluated over 4 years by numerous services.", + "The services included rheumatology, hematology, cardiology, and dermatology.", + "Blood cultures were negative on repeat occasions.", + "Eleven months prior to current presentation, he developed recurrent acute congestive heart failure exacerbation.", + "The exacerbations required multiple admissions.", + "Treatment involved diuretics and chest tubes.", + "The treatment provided limited short-term symptomatic relief.", + "On this presentation, the patient had symptoms consistent with an exacerbation of congestive heart failure.", + "He stated he had lost approximately 40 pounds over 6 months.", + "He denied any GI symptoms.", + "He denied fevers, chills, or night sweats.", + "Physical examination revealed the patient as pale.", + "Physical examination revealed the patient as afebrile.", + "Physical examination revealed the patient as hemodynamically stable.", + "He was noted to be cachectic with a weight of fifty-one kilograms.", + "Pitting edema of both lower extremities to the proximal shin was noted.", + "Hyperpigmentation was noted.", + "As observed on the initial CT scan, there was diffuse lymphadenopathy.", + "Right epitrochlear lymphadenopathy was noted.", + "Jugular venous distension was noted to 8 cm above the sternal angle.", + "A positive Kussmaul’s sign was observed on inspiration.", + "The patient had a 3/6 systolic ejection murmur.", + "There was no pericardial knock observed.", + "There was no oculomasticatory myorhythmia observed.", + "There was no supranuclear vertical gaze palsy observed.", + "Transthoracic echocardiogram imaging was reviewed from 2014 to 2016.", + "In 2014, subtle tethering of the mitral valve was noted.", + "The posterior leaflet had reduced excursion.", + "The mitral valve apparatus was apically displaced.", + "There was the observation of subtle diastolic doming over the anterior mitral leaflet.", + "In 2016, the anterior mitral valve was thickened with reduced excursion.", + "The posterior leaflet was fixed and cords with shortening were noted.", + "This was in keeping with pseudoprolapse.", + "There was systolic doming of the right coronary cusp over the aortic valve.", + "There was calcification from the commissural aspect of the aortic valve.", + "There was sparing of the base of the aortic valve.", + "There was the presence of septal shuttering in early diastole.", + "There was early inspiratory septal bounce/shift.", + "This was indicative of abnormal heart and lung interaction.", + "This was suggestive of early constrictive physiology.", + "A repeat transthoracic echocardiogram on admission showed a reduction in left ventricle systolic function.", + "The ejection fraction was 48%.", + "Severe mitral regurgitation was noted.", + "Moderate tricuspid regurgitation was noted.", + "Moderate aortic regurgitation was noted.", + "Worsening pulmonary hypertension was noted.", + "The right ventricular systolic pressure was 78 mmHg.", + "Calcific aortic valve changes were noted.", + "The calcific changes were felt to be post-inflammatory.", + "The mitral valve had an unusual appearance suggestive of prior valvulitis.", + "The valvulitis was in particular rheumatic in nature.", + "The pericardium was thickened.", + "The features were consistent with constrictive physiology.", + "Pericardial stripping and valvular surgery were proposed.", + "Perioperative findings consisted of thick pericardium.", + "The pericardium was densely adherent to the surrounding anatomy.", + "The mitral valve was grossly abnormal with fibrosis.", + "The fibrosis was in keeping with a rheumatic type process.", + "The mitral valve was replaced with a bioprosthetic valve.", + "The tricuspid valve had thickened leaflets.", + "The tricuspid valve was repaired with a ring annuloplasty.", + "The thickened aortic valve was addressed with primary repair.", + "The constellation of symptoms lent to a strong clinical suspicion of an atypical presentation of Whipple’s disease.", + "Duodenal biopsies were obtained two days post-op.", + "The biopsies were not consistent with Whipple’s disease.", + "The cardiac valves and pericardium pathology specimens were examined for PAS staining and PCR.", + "The cardiac specimens demonstrated numerous foamy macrophages filled with PAS positive material.", + "The PAS positive material was compatible with Whipple’s disease.", + "Tropheryma whipplei was identified by direct 16S rDNA PCR on the mitral valve.", + "The sequence match was > 99%.", + "The pathological changes were consistent with active endocarditis.", + "The pathological changes were consistent with active myocarditis.", + "The pathological changes were consistent with active pericarditis.", + "The endocarditis, myocarditis, and pericarditis were caused by T. whipplei.", + "The patient started treatment with IV Penicillin G for 14 days.", + "The patient was maintained on oral sulfamethoxazole-trimethoprim for long-term treatment.", + "Six months following diagnosis, the patient has had no complications.", + "Six months following diagnosis, the patient is clinically improving." + ], + "summary": "A previously healthy 56-year-old male presented with a four-year history of congestive heart failure with weight loss and fatigue. Notably, he had absent gastrointestinal symptoms. He went on to develop pan-valvular endocarditis and constrictive pericarditis requiring urgent cardiac surgery. A clinical diagnosis of Whipple’s disease was suspected, prompting duodenal biopsy sampling which was unremarkable, Subsequently, Tropheryma whipplei was identified by 16S rDNA PCR on the cardiac valvular tissue. He underwent prolonged antibiotic therapy with recovery of symptoms.", + "summary_subclaims": [ + "The patient is a 56-year-old male.", + "The patient had a four-year history of congestive heart failure.", + "The patient had weight loss.", + "The patient had fatigue.", + "The patient had absent gastrointestinal symptoms.", + "The patient developed pan-valvular endocarditis.", + "The patient developed constrictive pericarditis.", + "The patient required urgent cardiac surgery.", + "A clinical diagnosis of Whipple’s disease was suspected.", + "Duodenal biopsy sampling was unremarkable.", + "Tropheryma whipplei was identified by 16S rDNA PCR on the cardiac valvular tissue.", + "The patient underwent prolonged antibiotic therapy.", + "The patient had recovery of symptoms." + ] + }, + { + "id": "multiclinsum_test_1840_en.txt", + "fulltext": "A 67-year-old female underwent bilateral truncal vagotomy, cholecystectomy, Billroth-2 gastrectomy, and Roux-en-Y procedure for pyloric stenosis twenty years ago due to early dumping syndrome and sliding-type hiatal hernia. The liver left lobe was mobilized by dissecting the left triangular ligament (appendix fibrosa hepatis) to release the cardioesophageal junction and stomach fundus. The hiatal hernia defect was repaired with a constrictive primary suture. Roux-en-Y anastomosis was externally constricted, and the antidumping procedure was applied. There was no other procedure in the abdomen that could injure the bile ducts such as liver hilar and duodenal stump dissection. A penrose drain was placed under the left lobe of the liver at the level of the cardioesophageal junction. There was a 150 mL bile leak in 24 hours after the first day of surgery. Bile leakage was detected with MRCP on the left side of the left triangular ligament of the liver . The patient was reoperated, and no pathology was observed except for aberrant bile duct (a 3 mm diameter) with bile leakage at the site where the left liver triangular ligament (appendix fibrosa hepatis) was dissected at the observation by following the drain . The injured bile duct was ligated with the 3/0 prolene suture. On 7 day after the operation, all complaints resolved, and the patient was discharged without any problems in the postoperative period.", + "fulltext_subclaims": [ + "The patient is a 67-year-old female.", + "The patient underwent bilateral truncal vagotomy.", + "The patient underwent cholecystectomy.", + "The patient underwent Billroth-2 gastrectomy.", + "The patient underwent Roux-en-Y procedure.", + "The surgery was for pyloric stenosis.", + "The surgery was twenty years ago.", + "The surgery was due to early dumping syndrome.", + "The surgery was due to sliding-type hiatal hernia.", + "The liver left lobe was mobilized by dissecting the left triangular ligament.", + "The hiatal hernia defect was repaired with a constrictive primary suture.", + "Roux-en-Y anastomosis was externally constricted.", + "The antidumping procedure was applied.", + "There was no other procedure in the abdomen that could injure the bile ducts.", + "A penrose drain was placed under the left lobe of the liver.", + "There was a 150 mL bile leak in 24 hours after the first day of surgery.", + "Bile leakage was detected with MRCP on the left side of the left triangular ligament of the liver.", + "The patient was reoperated.", + "An aberrant bile duct with a 3 mm diameter was observed.", + "Bile leakage was at the site where the left liver triangular ligament was dissected.", + "The injured bile duct was ligated with the 3/0 prolene suture.", + "On 7 day after the operation, all complaints resolved.", + "The patient was discharged without any problems in the postoperative period." + ], + "summary": "We report the case of a 67-year-old female patient who was operated on due to dumping syndrome symptoms and hiatal hernia. There was a drainage of bile from the left side of the liver which was placed under the cardioesophageal junction. MRCP found bile esophageal in the left triangular ligament of the liver. Aberrant bile ducts were found in the left triangular ligament and ligated. The patient was discharged on the 7th day after operation.", + "summary_subclaims": [ + "The patient was a 67-year-old female.", + "The patient was operated on due to dumping syndrome symptoms.", + "The patient had a hiatal hernia.", + "There was a drainage of bile from the left side of the liver.", + "The drainage was placed under the cardioesophageal junction.", + "MRCP found bile esophageal in the left triangular ligament of the liver.", + "Aberrant bile ducts were found in the left triangular ligament.", + "The aberrant bile ducts were ligated.", + "The patient was discharged on the 7th day after operation." + ] + }, + { + "id": "multiclinsum_test_133_en.txt", + "fulltext": "Preceding availability of COVID-19 vaccination, a 58-year-old Caucasian male presented to his primary care provider with one-week of cough, low-grade fever, and general malaise. He was diagnosed with follicular lymphoma 10 months prior and received 6 cycles of chemo-immunotherapy (bendamustine and rituximab), achieving clinical remission, and received an additional dose of maintenance rituximab one month prior. An oropharyngeal swab was positive for SARS-CoV-2, but he did not require hospitalization at that time.\nTwenty-seven days after the initial positive swab, he developed hypoxemia prompting hospital admission. Initial NP swab was negative and computed tomography (CT) imaging demonstrated recurrent ground glass opacities with bilateral interstitial pneumonia, compatible with COVID-19. Blood tests revealed lymphopenia (0.1 × 109/L, normal: 0.7–3.5 × 109/L) with increased C-reactive protein (57.0 mg/L, normal: 0.0–8.0 mg/L) and ferritin (2047 μg/L, normal: 30–500ug/L). He improved with dexamethasone 6 mg daily for 10 days. However due to relapsing hypoxemia and radiographic progression, a diagnosis of organizing pneumonia as sequelae of COVID-19 was considered. Bronchoscopy was declined, and oral prednisone 50 mg daily was initiated with a planned dose taper.\nOn day 90, 73 days post admission, following ongoing reduction of prednisone (10 mg), the patient presented with new onset of pyrexia and recurrence of hypoxemia. RT-PCR testing was again positive by NP swab . The patient was re-initiated on dexamethasone with bronchoscopy performed. Bronchoalveolar lavage was both SARS-CoV-2 RT-PCR (Ct 18.7) and culture positive (1.17 × 104 pfu/mL, wild-type G clade) and negative for bacterial, mycobacterial, other viral and fungal growth. Transbronchial biopsies demonstrated active pneumonitis with occasional foci of organizing pneumonia, and patchy interstitial fibrosis. Symptoms were consistent with COVID-19 relapse and remdesivir was given (200 mg intravenous loading dose then 100 mg daily) for 5 days concurrently with dexamethasone . On day 107, there was clinical improvement with reduction in oxygen requirements to room air and RT-PCR Ct of 24.4 Subsequent investigations revealed hypogammaglobinemia (IgA 0.48 g/L, IgG 3.29 g/L, IgM 0.05 g/L (normal: 0.6–4.2 g/L, 6.8–18.0 g/L, 0.4–3.00 g/L, respectively), likely secondary to prior rituximab administration. He was initiated on monthly intravenous immunoglobulin. He clinically improved and was discharged home on day 107 with an oral dexamethasone (4 mg) taper. Viral culture load at time of discharge was not detectable.\nOn day 118 the patient re-presented to hospital with respiratory failure. A repeat SARS-CoV-2 RT-PCR swab was positive with Ct of 23.7and a viral culture load of 1.25 × 101 pfu/mL, suggestive of ongoing viral persistence and a third COVID-19 relapse . SARS-CoV-2 testing failed to demonstrate remdesivir resistance (supplementary material). He was re-treated with another course of remdesivir for 5 days with modest clinical improvement. Repeat CT scans demonstrated persistent, migratory bilateral ground glass opacities . Subsequent medical therapy included bamlanivimab 700 mg (day 133; one dose), IVIG 75 mg (days 137, 165 and 193; one dose each) and a third course of remdesivir (day 146; ten-day course). The patient demonstrated a gradual clinical recovery with progressive reduction in oxygen therapy and eventual negative swab by RT-PCR on day 189. On days 174 and 202, the mRNA-1273 COVID-19 vaccine was administered. On day 202 after initial presentation, he was ultimately discharged home with repeat COVID-19 swabs (days 209 and 224) negative. He has continued to improve with gradually increasing exercise tolerance.\nNotably, whole genome sequencing of the patient’s viral samples over the duration of the time-period demonstrated an identical sequence belonging to SARS-CoV-2 clade D614G equivalent to the PANGO B.1 lineage viral strain with a specific sublineage of B.1.160. A review of the local epidemiology during this period noted B.1.160 as the 12th highest lineage, accounting for only 1.4% of the those sequenced from the general population. Based on the sequencing results, relapse of infection by an identical virus strain was demonstrated rather than re-infection with different strains. Finally, serology testing completed was negative to the nucleocapsid antibody, however positive for the spike antibody (value of 1515.3AU/mL; positive threshold of > 50AU/mL).", + "fulltext_subclaims": [ + "The patient was a 58-year-old Caucasian male.", + "He had follicular lymphoma diagnosed 10 months prior.", + "He received 6 cycles of chemo-immunotherapy (bendamustine and rituximab).", + "He achieved clinical remission.", + "He received an additional dose of maintenance rituximab one month prior.", + "An oropharyngeal swab was positive for SARS-CoV-2.", + "He did not require hospitalization at that time.", + "Twenty-seven days after the initial positive swab, he developed hypoxemia.", + "Hypoxemia prompted hospital admission.", + "Initial NP swab was negative.", + "CT imaging demonstrated recurrent ground glass opacities.", + "CT imaging showed bilateral interstitial pneumonia.", + "CT findings were compatible with COVID-19.", + "Blood tests revealed lymphopenia (0.1 × 109/L).", + "C-reactive protein was 57.0 mg/L.", + "Ferritin was 2047 μg/L.", + "He improved with dexamethasone 6 mg daily for 10 days.", + "A diagnosis of organizing pneumonia as sequelae of COVID-19 was considered.", + "Bronchoscopy was declined.", + "Oral prednisone 50 mg daily was initiated.", + "On day 90, 73 days post admission, he presented with new onset of pyrexia.", + "RT-PCR testing was again positive by NP swab.", + "He was re-initiated on dexamethasone.", + "Bronchoscopy was performed.", + "Bronchoalveolar lavage was SARS-CoV-2 RT-PCR positive (Ct 18.7).", + "Bronchoalveolar lavage was culture positive (1.17 × 104 pfu/mL, wild-type G clade).", + "Transbronchial biopsies demonstrated active pneumonitis.", + "Symptoms were consistent with COVID-19 relapse.", + "Remdesivir was given (200 mg intravenous loading dose then 100 mg daily) for 5 days.", + "On day 107, there was clinical improvement.", + "Oxygen requirements were reduced to room air.", + "RT-PCR Ct was 24.4.", + "Subsequent investigations revealed hypogammaglobinemia.", + "IgA was 0.48 g/L.", + "IgG was 3.29 g/L.", + "IgM was 0.05 g/L.", + "Hypogammaglobinemia was likely secondary to prior rituximab administration.", + "He was initiated on monthly intravenous immunoglobulin.", + "He was discharged home on day 107.", + "On day 118, the patient re-presented to hospital with respiratory failure.", + "A repeat SARS-CoV-2 RT-PCR swab was positive with Ct of 23.7.", + "A viral culture load of 1.25 × 101 pfu/mL was noted.", + "This was suggestive of ongoing viral persistence.", + "This was suggestive of a third COVID-19 relapse.", + "SARS-CoV-2 testing failed to demonstrate remdesivir resistance.", + "He was re-treated with another course of remdesivir for 5 days.", + "Repeat CT scans demonstrated persistent, migratory bilateral ground glass opacities.", + "Medical therapy included bamlanivimab 700 mg (day 133; one dose).", + "Medical therapy included IVIG 75 mg (days 137, 165 and 193; one dose each).", + "Medical therapy included a third course of remdesivir (day 146; ten-day course).", + "The patient demonstrated a gradual clinical recovery.", + "Oxygen therapy was progressively reduced.", + "Repeat COVID-19 swabs were negative by RT-PCR on day 189.", + "On days 174 and 202, the mRNA-1273 COVID-19 vaccine was administered.", + "On day 202 after initial presentation, he was discharged home.", + "Repeat COVID-19 swabs (days 209 and 224) were negative.", + "Whole genome sequencing demonstrated an identical sequence belonging to SARS-CoV-2 clade D614G.", + "The viral strain was equivalent to the PANGO B.1 lineage.", + "The specific sublineage was B.1.160.", + "B.1.160 was the 12th highest lineage in the local population.", + "B.1.160 accounted for 1.4% of the sequenced viral strains.", + "Relapse of infection by an identical virus strain was demonstrated.", + "Serology testing was negative to the nucleocapsid antibody.", + "Serology testing was positive for the spike antibody (1515.3 AU/mL)." + ], + "summary": "We present a case of an immunocompromised patient with SARS-CoV-2 infection demonstrating prolonged infectious viral shedding for 189 days with virus cultivability and clinical relapse with an identical strain based on whole genome sequencing, requiring a multi-modal therapeutic approach. We correlated clinical parameters, PCR cycle thresholds and viral culture until eventual resolution.", + "summary_subclaims": [ + "We present a case of an immunocompromised patient with SARS-CoV-2 infection.", + "The patient demonstrated prolonged infectious viral shedding for 189 days.", + "Virus cultivability was documented.", + "Clinical relapse occurred with an identical strain based on whole genome sequencing.", + "A multi-modal therapeutic approach was required.", + "Clinical parameters were correlated.", + "PCR cycle thresholds were correlated.", + "Viral culture was correlated until eventual resolution." + ] + }, + { + "id": "multiclinsum_test_546_en.txt", + "fulltext": "This case was a 44-year-old male patient. During his routine physical examination, an approximately 6.0 × 5.5 cm inhomogeneous echo mass was found incidentally in the right lobe of the liver by abdominal ultrasound. The patient denied any accompanying symptoms such as anorexia, abdominal distension or pain, fever, or weight loss. He had a 5-year history of hypertension and took felodipine tablets to control blood pressure. The patient had a 20-year drinking history, equivalent to about 40 g ethanol/day. He had no history of intravenous drug use, exposure to herbal medicines or health care products, or surgical and familial genetic disease. Routine blood analysis was conducted and the values for various tests—liver and kidney function, coagulation function, and tumor markers (alpha-fetoprotein, carcinoembryonic antigen, and carbohydrate antigen 19-9)—were within the normal range. Serological tests for hepatitis B and hepatitis C were negative. Autoantibodies related to autoimmune liver disease, thyroid function, and ceruloplasmin were within the normal range. Physical examination showed no positive disease indicators.\nThe patient then underwent an imaging examination. A second ultrasound revealed multiple small irregularly shaped hypoechoic masses with slightly hyperechoic septae in segment 6 of the liver (S6), and a total size of approximately 6.0 × 5.5 cm. Contrast-enhanced ultrasound (CEUS) showed a cystic-solid lesion with honeycomb-like enhancement in the arterial phase, in which multiple disordered unreinforced tubular columnar areas were seen. No obvious papillary structure was found. The enhanced region was slowly cleared in the portal and delayed phases. Abdominal contrast-enhanced computed tomography (CT) scans showed a honeycomb-like cystic-solid lesion with a tubulocystic manifestation lacking well-defined borders in S6 and no dilation of the major intrahepatic bile duct in the background liver. The cystic components were low-density and showed no enhancement in the arterial phase. The solid components, which were septa or the cystic wall, were more enhanced than the normal hepatic parenchyma in the arterial and portal phases and were consistent with normal hepatic parenchyma in the equilibrium phase. Abdominal magnetic resonance imaging (MRI) showed an irregular-shaped multicystic mass with a mixed signal shadow in S6. The lesion was revealed as an irregular tubular low-density area on T1-weighted images and a high-intensity area on T2-weighted images, which were interspersed with strips of slightly higher signal shadows. The signal of the solid component of the intermediate inclusion was not high on diffusion-weighted imaging (DWI), while the apparent diffusion coefficient (ADC) signal was high, indicating that the dispersion was not limited. The solid components of the lesion were enhanced in the late arterial phase by injecting the contrast medium, gadoxetic acid disodium. In the hepatobiliary phase, the whole lesion was low signal. The mass had no obvious invasion into adjacent structures and was thought to be benign. Magnetic resonance cholangiopancreatography (MRCP) showed intrahepatic hybrid-density cystic-solid masses that did not communicate with the bile duct. Intrahepatic and extrahepatic bile ducts were not dilated. No definite abnormal signal shadow was found in the bile duct cavity and gallbladder. Imaging examination did not reveal any bile duct stones . To exclude liver metastatic carcinoma caused by gastrointestinal malignancies, gastroscopy and colonoscopy were performed and no obvious abnormalities were detected. Duodenal papilla was normal, and no colloidal mucus was present. Based on these results, the lesion was suspected to be MCBH but other diseases such as HMH, VMC, Caroli's disease, biliary cystadenoma, and CHFC could not yet be excluded.\nSince MCBH is a localized cystic-solid lesion, it can be difficult to diagnose by needle biopsy due to limited sampling of the lesion and heterogeneous distribution of the tumor components. After communicating with the patient and his relatives, surgical resection was performed. This was an open operation. The lesion could not be observed in the liver surface. The intraoperative ultrasonic testing was performed and the lesion was located in the right posterior segment VI of liver. Anatomical resection of segment VI was performed and the resection margin was more than 1 cm to the lesion. No enlarged lymph nodes were found during the operation. The residual liver had no tumors and showed healthy texture by intraoperative ultrasound. The operation was successful, lasting about 2 h, and the intraoperative bleeding was 100 ml.\nThe surgical specimen revealed an approximately 6.0 × 5.5 cm nodular mass. A cystic-solid lesion with a honeycomb appearance and gray-white, medium texture, was seen in a section of the resected specimen. The lesion was composed of diffuse, cystically dilated ductal structures that were approximately 0.1–1.5 cm in diameter and surrounded by fibrous tissue. The lesion was filled with clear, colorless liquid surrounded by normal liver tissue.\nLow-power microscopy displayed a relative clearance boundary in the lesion area that consisted of ductal structures, periductal glands, fibrous connective tissues, and blood vessels. Ductal structures were cystically dilated and irregularly angulated. Bile-stained materials were observed in some ducts and the peripheral bile ducts were not dilated. High-power microscopy showed that the ductal epithelium was composed of a monolayered columnar and cuboidal epithelium that was morphologically identical to biliary epithelium. Fibrous connective tissue around the ducts contained only mild lymphocytic infiltration. Normal hepatocytes were observed between the cystic ducts. There were no smooth muscle elements or ovarian-like stroma, and there were no atypical cells or papillary growth of the epithelial cells. Synchronous biliary hamartomas, nodules, steatosis, or significant fibrosis were not observed in the non-lesion liver tissue. Immunohistochemistry showed CK7 and CK19 positivity in the dilated duct epithelium and CD34 positivity in the vessels. Ki-67 antigen staining revealed the proliferative activity of individual cells .", + "fulltext_subclaims": [ + "The patient was a 44-year-old male.", + "An approximately 6.0 × 5.5 cm inhomogeneous echo mass was found in the right lobe of the liver by abdominal ultrasound.", + "The patient denied any accompanying symptoms such as anorexia, abdominal distension or pain, fever, or weight loss.", + "He had a 5-year history of hypertension and took felodipine tablets.", + "He had a 20-year drinking history, equivalent to about 40 g ethanol/day.", + "Routine blood analysis showed values within the normal range for liver and kidney function, coagulation function, and tumor markers.", + "Serological tests for hepatitis B and hepatitis C were negative.", + "Autoantibodies related to autoimmune liver disease, thyroid function, and ceruloplasmin were within the normal range.", + "A second ultrasound revealed multiple small irregularly shaped hypoechoic masses with slightly hyperechoic septae in segment 6 of the liver.", + "Contrast-enhanced ultrasound showed a cystic-solid lesion with honeycomb-like enhancement in the arterial phase.", + "The enhanced region was slowly cleared in the portal and delayed phases.", + "Abdominal contrast-enhanced CT showed a honeycomb-like cystic-solid lesion with a tubulocystic manifestation in segment 6.", + "The cystic components were low-density and showed no enhancement in the arterial phase.", + "The solid components were more enhanced than the normal hepatic parenchyma in the arterial and portal phases.", + "Abdominal MRI showed an irregular-shaped multicystic mass with a mixed signal shadow in segment 6.", + "The lesion was revealed as an irregular tubular low-density area on T1-weighted images.", + "The lesion was revealed as a high-intensity area on T2-weighted images.", + "The solid component of the intermediate inclusion was not high on diffusion-weighted imaging.", + "The apparent diffusion coefficient signal was high, indicating that the dispersion was not limited.", + "The solid components of the lesion were enhanced in the late arterial phase by injecting the contrast medium, gadoxetic acid disodium.", + "In the hepatobiliary phase, the whole lesion was low signal.", + "MRCP showed intrahepatic hybrid-density cystic-solid masses that did not communicate with the bile duct.", + "Intrahepatic and extrahepatic bile ducts were not dilated.", + "No definite abnormal signal shadow was found in the bile duct cavity and gallbladder.", + "Imaging examination did not reveal any bile duct stones.", + "Gastroscopy and colonoscopy were performed and no obvious abnormalities were detected.", + "The lesion was suspected to be MCBH.", + "Other diseases such as HMH, VMC, Caroli's disease, biliary cystadenoma, and CHFC could not yet be excluded.", + "Surgical resection was performed.", + "The operation was an open operation.", + "Anatomical resection of segment VI was performed.", + "The resection margin was more than 1 cm to the lesion.", + "The operation was successful, lasting about 2 h.", + "The intraoperative bleeding was 100 ml.", + "The surgical specimen revealed an approximately 6.0 × 5.5 cm nodular mass.", + "The lesion was composed of diffuse, cystically dilated ductal structures that were approximately 0.1–1.5 cm in diameter.", + "The lesion was filled with clear, colorless liquid surrounded by normal liver tissue.", + "Low-power microscopy displayed a relative clearance boundary in the lesion area.", + "Ductal structures were cystically dilated and irregularly angulated.", + "Bile-stained materials were observed in some ducts.", + "The ductal epithelium was composed of a monolayered columnar and cuboidal epithelium.", + "Fibrous connective tissue around the ducts contained only mild lymphocytic infiltration.", + "There were no smooth muscle elements or ovarian-like stroma.", + "There were no atypical cells or papillary growth of the epithelial cells.", + "Synchronous biliary hamartomas, nodules, steatosis, or significant fibrosis were not observed in the non-lesion liver tissue.", + "Immunohistochemistry showed CK7 and CK19 positivity in the dilated duct epithelium.", + "CD34 positivity was observed in the vessels.", + "Ki-67 antigen staining revealed the proliferative activity of individual cells." + ], + "summary": "This case study involves a middle-aged male patient with a history of drinking but no other liver diseases. A routine ultrasound examination showed a 6.0 × 5.5 cm inhomogeneous echo mass in the right lobe of the liver. The patient experienced no discomfort or other symptoms, and blood tests were normal. Imaging revealed a localized cystic-solid neoplasm in segment 6 of the liver that did not have the features of a malignant tumor. Surgical resection was performed. Based on imaging, macroscopic examination, and histological results, a final diagnosis of MCBH was made.", + "summary_subclaims": [ + "The patient is a middle-aged male.", + "The patient has a history of drinking.", + "The patient has no other liver diseases.", + "A routine ultrasound examination showed a 6.0 × 5.5 cm inhomogeneous echo mass in the right lobe of the liver.", + "The patient experienced no discomfort.", + "The patient had no other symptoms.", + "Blood tests were normal.", + "Imaging revealed a localized cystic-solid neoplasm in segment 6 of the liver.", + "The neoplasm did not have the features of a malignant tumor.", + "Surgical resection was performed.", + "A final diagnosis of MCBH was made." + ] + }, + { + "id": "multiclinsum_test_900_en.txt", + "fulltext": "During the course of a respiratory infection, a 26-year old male exhibited gait imbalance, numbness and “pins and needles” the lower-limbs. Based on the patient´s description, the sensory symptoms were present in whole lower legs from the hips and proximal thigh distally (i.e. approximately in the distribution from L3 to S1). The patient suffered from cough and fever for 2 days prior the onset of neurological symptoms. His C-reactive protein (CRP) was 160 mg/L (normal range 0-5 mg/L). The chest X-ray, abdominal ultrasound and echocardiography were normal. The paranasal sinuses radiography revealed a mild gas-fluid level in the left maxillary sinus. Starting from the 4th day of the respiratory symptoms (2 day after the onset of neurological symptoms), the patient was treated with amoxicillin/clavulanic acid for seven days, first five days intravenously 1000 mg/200 mg every eight hours in the department of internal medicine of a small local hospital and two last days per orally 875 mg/125 mg twice a day with the good effect on respiratory functions and fever, but without any impact in neurological symptoms and signs. The neurological symptoms were, however, not dominant from the patient’s perspective and the patient was not examined by any neurologist at the beginning of the symptoms. The residual neurological symptoms (numbness in the lower legs and difficulties running and tandem-walking) remained stable for another three years. Since the level of disability was considered mild, the patient was still not referred to a neurologist. The patient’s family history was unremarkable, patient’s mother suffers from high blood pressure and type 2 diabetes mellitus, his father has high blood pressure. No neurological or autoimmune diseases appeared in the family. The patient suffered from mononucleosis at the age of ten and mumps at the age of 17, otherwise is the patient’s medical history unremarkable.\nBy the time the patient had reached the age of 29, a subacute progression (two weeks) of imbalance had resulted in severe walking problems and he was admitted to the neurological department of the secondary hospital. Neurological examination revealed perianogenital hypesthesia with sphincter dysfunction (urinary retention¨and incomplete empting) and severe positive and negative sensory symptoms in the lower limbs, including L3-S2 hypoesthesia, impaired joint position sense and loss of vibration sense, and severe lower limbs and gait ataxia. Deep-tendon reflexes and the plantar reflex were absent. The patient was unable to walk correctly in tandem gait, or to run due to ataxia, he was unable to walk unsupported for more than few meters and did not exhibit any muscle weakness. His EDSS was 6.0. The clinical findings in the cranial nerves and upper extremities were completely normal and his cognitive status was intact.\nAn MRI (1.5 T) scan of the brain and cervical, thoracic, and lumbar spine performed ten days after symptoms onset proved normal . In the cerebrospinal fluid (CSF), there were no indications of neuro-infection, no oligoclonal bands appeared in CSF or in the serum. CSF protein was elevated to 2.24 g/L (normal range 0.15-0.45 g/L). Initial nerve conduction studies and needle electromyography (NCS/EMG) examinations were normal.\nBased on the clinical presentation, relapsing-remitting course, elevated CSF protein levels and normal brain and spine MRI, a diagnosis of inflammatory polyneuropathy considered and the patient was therefore treated with high-dose steroids (3 g of methylprednisolone), resulting in a significant reduction of complaints with residual symptoms. Thus, the chronic treatment with prednisone (20 mg/day) commenced, and the patient was referred to a tertiary neuromuscular center.\nIn this center, a follow-up NCS examination confirmed the absence of demyelinating changes in all the peripheral nerves examined in both upper and lower limbs. The spinal MRI did not show any abnormality of the lumbar or sacral nerve roots (i.e. no thickening or a tube-shaped enlargement). The diagnosis of inflammatory neuropathy including chronic immune sensory polyradiculopathy (CISP) was therefore considered improbable and further investigation undertaken [, ]. Visual, brainstem auditory and motor-evoked potentials were normal. Somatosensory-evoked potentials established a central lesion of the spinal somatosensory pathway to the lower extremities (with no abnormality in the upper extremities) .\nA range of laboratory tests was performed to investigate the following antibodies: the paraneoplastic (anti-Hu, anti-Ri, anti-Yo, anti-CV2, anti-Amphiphysin, anti-Ma1, anti-Ma2), the infectious (including syphilis and HIV) and the autoimmune (including anti-nuclear antibodies, antibodies against extractable nuclear antigens, anti-double- and single-stranded DNA; anti-neutrophil cytoplasmic antibodies, anticardiolipin antibodies, anti-cyclic citrullinated peptide antibodies and anti-aquaporin-4 (AQP4)), all proved negative. The blood levels of creatine kinase, myoglobin, vitamin B12, B9, Cu, thyroid-stimulating hormone, thyroxine and carbohydrate-deficient transferrin were normal. Eventually, anti-MOG antibodies were detected by immunofluorescence Euroimmun fixed cell-based assay (titer 1:80).\nA diagnosis of MRI-negative MOGAD myelitis was established and, in response to persisting neurological symptoms, the patient was retreated with high-dose steroids (3 g of methylprednisolone), to no significant effect. Long-term treatment with 100 mg azathioprine was started (a reduced dose in the light of lower thiopurine methyltransferase activity). The previous treatment with 20 mg prednisone was progressively discontinued over the course of six months . The medication is well tolerated; the patient had no complaints related specifically to the drug. The course of the disease was relapsing. There were no signs of relapse-independent progression.\nCurrently, the patient has been relapse-free and clinically stable for almost three years. MRIs of the brain and the spinal cord six months later remained normal. Anti-MOG seropositivity was repeatedly proven during remission by visual observation on a fluorescence microscope immunofluorescence Euroimmun fixed cell-based assay (titer 1:80 to 1:40). The patient’s optical coherence tomography remained normal.\nAt the age of 31, the patient currently exhibits mild negative sensory symptoms in the distal parts of the lower limbs, areflexia of the lower limbs, impaired sense of vibration and joint position, and moderate gait and lower limb ataxia. Tandem walking and running are not possible. His expanded disability status scale stands at 3.5 (cerebellar and sensitive 3, other functional systems normal). Patient´s cognitive functions are within normal range.", + "fulltext_subclaims": [ + "A 26-year old male exhibited gait imbalance, numbness and “pins and needles” in the lower-limbs during a respiratory infection.", + "The sensory symptoms were present in whole lower legs from the hips and proximal thigh distally.", + "The patient suffered from cough and fever for 2 days prior to the onset of neurological symptoms.", + "The patient's C-reactive protein (CRP) was 160 mg/L.", + "The chest X-ray, abdominal ultrasound and echocardiography were normal.", + "The paranasal sinuses radiography revealed a mild gas-fluid level in the left maxillary sinus.", + "The patient was treated with amoxicillin/clavulanic acid for seven days.", + "The first five days of treatment were intravenous 1000 mg/200 mg every eight hours.", + "The last two days of treatment were oral 875 mg/125 mg twice a day.", + "The treatment had a good effect on respiratory functions and fever.", + "The treatment had no impact on neurological symptoms and signs.", + "The neurological symptoms were not dominant from the patient’s perspective.", + "The patient was not examined by any neurologist at the beginning of the symptoms.", + "The residual neurological symptoms remained stable for another three years.", + "The patient’s family history was unremarkable.", + "The patient’s mother suffers from high blood pressure and type 2 diabetes mellitus.", + "The patient’s father has high blood pressure.", + "No neurological or autoimmune diseases appeared in the family.", + "The patient suffered from mononucleosis at the age of ten.", + "The patient suffered from mumps at the age of 17.", + "The patient’s medical history was otherwise unremarkable.", + "By the time the patient had reached the age of 29, a subacute progression of imbalance had resulted in severe walking problems.", + "The patient was admitted to the neurological department of the secondary hospital.", + "Neurological examination revealed perianogenital hypesthesia with sphincter dysfunction.", + "The patient had urinary retention and incomplete emptying.", + "The patient had severe positive and negative sensory symptoms in the lower limbs.", + "The patient had L3-S2 hypoesthesia.", + "The patient had impaired joint position sense and loss of vibration sense.", + "The patient had severe lower limbs and gait ataxia.", + "Deep-tendon reflexes and the plantar reflex were absent.", + "The patient was unable to walk correctly in tandem gait.", + "The patient was unable to run due to ataxia.", + "The patient was unable to walk unsupported for more than few meters.", + "The patient did not exhibit any muscle weakness.", + "The patient’s EDSS was 6.0.", + "The clinical findings in the cranial nerves and upper extremities were completely normal.", + "The patient’s cognitive status was intact.", + "An MRI scan of the brain and cervical, thoracic, and lumbar spine performed ten days after symptoms onset proved normal.", + "There were no indications of neuro-infection in the cerebrospinal fluid.", + "No oligoclonal bands appeared in CSF or in the serum.", + "CSF protein was elevated to 2.24 g/L.", + "Initial nerve conduction studies and needle electromyography examinations were normal.", + "A diagnosis of inflammatory polyneuropathy was considered.", + "The patient was treated with high-dose steroids (3 g of methylprednisolone).", + "The treatment resulted in a significant reduction of complaints with residual symptoms.", + "Chronic treatment with prednisone (20 mg/day) commenced.", + "The patient was referred to a tertiary neuromuscular center.", + "A follow-up NCS examination confirmed the absence of demyelinating changes in all the peripheral nerves examined.", + "The spinal MRI did not show any abnormality of the lumbar or sacral nerve roots.", + "The diagnosis of inflammatory neuropathy including chronic immune sensory polyradiculopathy was considered improbable.", + "Visual, brainstem auditory and motor-evoked potentials were normal.", + "Somatosensory-evoked potentials established a central lesion of the spinal somatosensory pathway to the lower extremities.", + "A range of laboratory tests was performed to investigate the following antibodies: the paraneoplastic, the infectious, and the autoimmune.", + "All antibody tests proved negative.", + "The blood levels of creatine kinase, myoglobin, vitamin B12, B9, Cu, thyroid-stimulating hormone, thyroxine and carbohydrate-deficient transferrin were normal.", + "Anti-MOG antibodies were detected by immunofluorescence Euroimmun fixed cell-based assay (titer 1:80).", + "A diagnosis of MRI-negative MOGAD myelitis was established.", + "The patient was retreated with high-dose steroids (3 g of methylprednisolone), to no significant effect.", + "Long-term treatment with 100 mg azathioprine was started.", + "The previous treatment with 20 mg prednisone was progressively discontinued over the course of six months.", + "The medication is well tolerated.", + "The patient had no complaints related specifically to the drug.", + "The course of the disease was relapsing.", + "There were no signs of relapse-independent progression.", + "The patient has been relapse-free and clinically stable for almost three years.", + "MRIs of the brain and the spinal cord six months later remained normal.", + "Anti-MOG seropositivity was repeatedly proven during remission by visual observation on a fluorescence microscope immunofluorescence Euroimmun fixed cell-based assay (titer 1:80 to 1:40).", + "The patient’s optical coherence tomography remained normal.", + "At the age of 31, the patient exhibits mild negative sensory symptoms in the distal parts of the lower limbs.", + "The patient has areflexia of the lower limbs.", + "The patient has impaired sense of vibration and joint position.", + "The patient has moderate gait and lower limb ataxia.", + "Tandem walking and running are not possible.", + "The patient’s expanded disability status scale stands at 3.5.", + "Patient’s cognitive functions are within normal range." + ], + "summary": "This contribution presents a unique case report of a young male patient exhibiting relapsing myelitis with normal spinal cord and brain magnetic resonance imaging. Comprehensive diagnostic assessment revealed myelin-oligodendrocyte glycoprotein-IgG-associated disorder.", + "summary_subclaims": [ + "This contribution presents a unique case report of a young male patient.", + "The patient exhibited relapsing myelitis.", + "The patient had normal spinal cord magnetic resonance imaging.", + "The patient had normal brain magnetic resonance imaging.", + "Comprehensive diagnostic assessment revealed myelin-oligodendrocyte glycoprotein-IgG-associated disorder." + ] + }, + { + "id": "multiclinsum_test_2156_en.txt", + "fulltext": "A 47-year-old male, who hospitalized due to a giant scrotal tumor. He has a history of chronic alcoholism, developed numerous soft masses in the anterior neck, supraclavicular fossa, nape, bilateral arms, and shoulders 10 years ago. The tumors were painless and gradually enlarged in size. Five years ago, the patient developed a soft mass in the scrotum. The scrotal mass rapidly increased in size, he complained that hindering his ability to have sexual activity. Furthermore, the patient found it difficult to perform his daily activities. A physical examination revealed masses in the anterior neck, nape, shoulder, upper back, and scrotum. The mass was soft and poorly defined. The largest one was the scrotal swelling, causing expansion of the scrotal skin and buried penis . The penis could not be palpated if it was not erect; a short portion of the penis protruding to the surface could be manipulated during an erection, the prepuce and meatus were not abnormal. Normal-sized testicles were palpable in addition to the tumor, which moved independent of the tumor. His BMI was 26. Magnetic resonance imaging (MRI) revealed non-encapsulated adipose tissue on either side of the scrotum . An excision biopsy revealed a benign lipomatous tissue. Thyroid ultrasound image and thyroid hormones was normal. The levels of lipid in the blood, including cholesterol and triglycerides were within normal range. Liver function test results were abnormal. The levels of factors II, V, and VII were decreased, which in turn reduced the thrombocyte count and PTT levels. Thus, the patient was treated preoperatively with infusions of fresh frozen plasma and vitamin K.\nAn incision was made at the midline of the scrotal skin, and the tumor was dissected from the scrotal skin and surrounding tissues. The bilateral epididymis, spermatic cord, and testes were preserved. The lower part of the tumor could be easily dissected from the scrotal subcutaneous tissue. However, it was firmly attached to the scrotal skin. The resected fatty tumor was pale yellow, multi-lobed, and weighed 1650 g. The excess skin was excised in a wedge shape between the anterior and posterior scrotal regions to preserve the flap supplied by the anterior and posterior scrotal arteries . The patient was advised for quitting alcohol, weight loss after operation. At 3 months postoperatively, the patient confessed that he was able to perform normal sexual activity and his quality of life was improved.", + "fulltext_subclaims": [ + "The patient is a 47-year-old male.", + "He was hospitalized due to a giant scrotal tumor.", + "He has a history of chronic alcoholism.", + "He developed numerous soft masses in the anterior neck, supraclavicular fossa, nape, bilateral arms, and shoulders 10 years ago.", + "The tumors were painless.", + "The tumors gradually enlarged in size.", + "Five years ago, the patient developed a soft mass in the scrotum.", + "The scrotal mass rapidly increased in size.", + "The scrotal mass hindered his ability to have sexual activity.", + "The patient found it difficult to perform his daily activities.", + "A physical examination revealed masses in the anterior neck, nape, shoulder, upper back, and scrotum.", + "The mass was soft and poorly defined.", + "The largest one was the scrotal swelling.", + "The scrotal swelling caused expansion of the scrotal skin.", + "The scrotal swelling buried the penis.", + "The penis could not be palpated if it was not erect.", + "A short portion of the penis protruding to the surface could be manipulated during an erection.", + "The prepuce and meatus were not abnormal.", + "Normal-sized testicles were palpable in addition to the tumor.", + "The tumor moved independent of the testes.", + "His BMI was 26.", + "MRI revealed non-encapsulated adipose tissue on either side of the scrotum.", + "An excision biopsy revealed a benign lipomatous tissue.", + "Thyroid ultrasound image and thyroid hormones were normal.", + "The levels of lipid in the blood, including cholesterol and triglycerides, were within normal range.", + "Liver function test results were abnormal.", + "The levels of factors II, V, and VII were decreased.", + "The thrombocyte count and PTT levels were reduced.", + "The patient was treated preoperatively with infusions of fresh frozen plasma.", + "The patient was treated preoperatively with vitamin K.", + "An incision was made at the midline of the scrotal skin.", + "The tumor was dissected from the scrotal skin and surrounding tissues.", + "The bilateral epididymis, spermatic cord, and testes were preserved.", + "The lower part of the tumor could be easily dissected from the scrotal subcutaneous tissue.", + "The tumor was firmly attached to the scrotal skin.", + "The resected fatty tumor was pale yellow, multi-lobed, and weighed 1650 g.", + "Excess skin was excised in a wedge shape between the anterior and posterior scrotal regions.", + "The flap supplied by the anterior and posterior scrotal arteries was preserved.", + "The patient was advised to quit alcohol after operation.", + "The patient was advised for weight loss after operation.", + "At 3 months postoperatively, the patient was able to perform normal sexual activity.", + "At 3 months postoperatively, the patient's quality of life was improved." + ], + "summary": "Here, we report a patient with Donhouser's type III Madelung's disease. A 47-year-old male patient presented with a giant fatty scrotal tumor that caused deformation of the scrotum and penis, made it difficult to perform daily activities, and hindered sexual activity. The adipose tumor was completely removed using a midline scrotal incision. The scrotum was reconstructed with bilateral anterior and posterior scrotal skin flaps. The excess skin was cut into a wedge shape between the anterior and posterior scrotal regions.", + "summary_subclaims": [ + "The patient had Donhouser's type III Madelung's disease.", + "The patient was a 47-year-old male.", + "The patient presented with a giant fatty scrotal tumor.", + "The tumor caused deformation of the scrotum and penis.", + "The tumor made it difficult to perform daily activities.", + "The tumor hindered sexual activity.", + "The adipose tumor was completely removed using a midline scrotal incision.", + "The scrotum was reconstructed with bilateral anterior and posterior scrotal skin flaps.", + "The excess skin was cut into a wedge shape between the anterior and posterior scrotal regions." + ] + }, + { + "id": "multiclinsum_test_3290_en.txt", + "fulltext": "History of Presentation\nA 50-year-old man with paroxysmal atrial fibrillation (AF) presented to our institution (University of Illinois-Chicago, Chicago, Illinois, USA) for AF ablation and left atrial appendage occlusion (LAAO) device placement. His blood pressure was 138/81 mm Hg, his heart rate was 73 beats/min, his temperature was 37.1 °C, and his oxygen saturation was 99% on room air. He had unremarkable physical examination findings.\n\nPast Medical History\nThe patient’s past medical history was otherwise significant for hypertension and coronary artery disease with previous percutaneous coronary intervention to the left anterior descending and circumflex arteries. His CHA2DS2-VASc score was elevated at 2, but he was hesitant to start therapeutic anticoagulation because he was a boxer and occasionally received blows to the head. An performed echocardiogram in 2021 found mild dilatation of the left atrium (LA) and an ejection fraction of 55% by visual estimate.\n\nInvestigations\nWhile evaluating the left atrial appendage (LAA) for LAAO device closure, a transesophageal echocardiogram (TEE) was performed because computed tomography was not performed preoperatively. The TEE appeared to show a membrane covering the ostium of the LAA. Color Doppler imaging did not reveal any flow in or out of the LAA past the membrane. Further imaging with intracardiac echocardiography (ICE) was performed to confirm this finding.\n\nThe ICE catheter was advanced into the LA directly, and color Doppler imaging again demonstrated no flow into or out of the appendage through or around the membrane. A force-sensing ablation catheter was advanced under direct ICE and electroanatomical mapping (EAM) visualization, and stable contact and recordable electrograms were confirmed on the membrane. Intravenous ultrasound contrast material was administered, and no contrast flow was noted into the LAA beyond the membrane. For additional confirmation, an iodinated contrast injection at the mouth of the appendage under fluoroscopy demonstrated no connection to the main body of the LA.\n\nConventional 3-dimensional EAM was then performed of the LA by using a mapping catheter. Appropriate signals were observed from the pulmonary veins. When the catheter was carefully advanced toward the LAA, it could not enter the appendage ostium. Instead, the catheter detected electrical activity. Electroanatomical mapping of the LAA membrane was performed. Notably, the ablation catheter and the high-density mapping catheter detected normal atrial voltage on the membrane. They demonstrated general atrial capture with low output pacing on the membrane, a finding suggesting atrial myocardial tissue.\n\nManagement\nThe LAAO device was not implanted in the patient because of the presence of the membrane. AF ablation was still performed with successful radiofrequency pulmonary vein isolation. No ablation was performed directly over the membrane. At the end of the procedure, the membrane covering the orifice of the LAA was confirmed to be still intact and completely obstructed flow into the appendage on the basis of color Doppler and repeat bubble study. The patient was then extubated and had an uncomplicated recovery.\n\nFollow-Up\nThe patient was in sinus rhythm at 2- and 4-week follow-up visits post ablation and was asymptomatic from the standpoint of AF. The patient did not have any complications after the procedure. He received maintenance oral anticoagulation for the postablation blanking period, with plans to discontinue it afterward.", + "fulltext_subclaims": [ + "The patient is a 50-year-old man.", + "The patient has paroxysmal atrial fibrillation.", + "The patient presented for AF ablation and LAAO device placement.", + "The patient's blood pressure was 138/81 mm Hg.", + "The patient's heart rate was 73 beats/min.", + "The patient's oxygen saturation was 99% on room air.", + "The patient had unremarkable physical examination findings.", + "The patient's past medical history included hypertension.", + "The patient had coronary artery disease with prior percutaneous coronary intervention.", + "The patient's CHA2DS2-VASc score was 2.", + "The patient was hesitant to start therapeutic anticoagulation.", + "An echocardiogram in 2021 found mild dilatation of the left atrium.", + "The ejection fraction was estimated at 55%.", + "A transesophageal echocardiogram was performed.", + "The TEE showed a membrane covering the ostium of the LAA.", + "Color Doppler imaging did not reveal any flow in or out of the LAA past the membrane.", + "Intracardiac echocardiography was performed.", + "Color Doppler imaging with ICE again demonstrated no flow into or out of the appendage.", + "Intravenous ultrasound contrast material was administered.", + "No contrast flow was noted into the LAA beyond the membrane.", + "An iodinated contrast injection at the mouth of the appendage demonstrated no connection to the main body of the LA.", + "Conventional 3-dimensional EAM was performed of the LA.", + "Appropriate signals were observed from the pulmonary veins.", + "The catheter could not enter the appendage ostium.", + "The catheter detected electrical activity.", + "Electroanatomical mapping of the LAA membrane was performed.", + "The ablation catheter and high-density mapping catheter detected normal atrial voltage on the membrane.", + "Low output pacing on the membrane demonstrated general atrial capture.", + "The LAAO device was not implanted in the patient.", + "AF ablation was performed with successful radiofrequency pulmonary vein isolation.", + "No ablation was performed directly over the membrane.", + "The membrane covering the orifice of the LAA was confirmed to be intact.", + "The membrane completely obstructed flow into the appendage.", + "The patient was extubated.", + "The patient had an uncomplicated recovery.", + "The patient was in sinus rhythm at 2- and 4-week follow-up visits.", + "The patient was asymptomatic from the standpoint of AF.", + "The patient did not have any complications after the procedure.", + "The patient received maintenance oral anticoagulation for the postablation blanking period.", + "The patient had plans to discontinue anticoagulation after the blanking period." + ], + "summary": "A 50-year-old man with paroxysmal atrial fibrillation presented for LAA occlusion device implantation and atrial fibrillation ablation. Transesophageal and intracardiac echocardiography revealed a membrane completely occluding the LAA ostium, as confirmed by Doppler imaging, fluoroscopy, and electroanatomical mapping. No LAA occlusion device was implanted, but AF ablation was successfully performed. The patient was in sinus rhythm and was asymptomatic at follow-up.", + "summary_subclaims": [ + "The patient is a 50-year-old man.", + "The patient has paroxysmal atrial fibrillation.", + "The patient presented for LAA occlusion device implantation.", + "The patient presented for atrial fibrillation ablation.", + "Transesophageal and intracardiac echocardiography revealed a membrane completely occluding the LAA ostium.", + "Doppler imaging confirmed the membrane occluding the LAA ostium.", + "Fluoroscopy confirmed the membrane occluding the LAA ostium.", + "Electroanatomical mapping confirmed the membrane occluding the LAA ostium.", + "No LAA occlusion device was implanted.", + "Atrial fibrillation ablation was successfully performed.", + "The patient was in sinus rhythm at follow-up.", + "The patient was asymptomatic at follow-up." + ] + }, + { + "id": "multiclinsum_test_978_en.txt", + "fulltext": "A 78-year-old Chinese woman, gravida 2, para 2, with menopause at age 51, presented to the Department of Endocrinology with a 2-week history of 5 × 3 × 1.5 cm mushroom-like lump in her right thigh . According to the medical history, the patient was a housewife and confirmed that she was not exposed to excessively professional, accidental, or medical UV radiation. She had a 30-year history of type 2 DM and her HbA1c was 8.4 % (68mMol/mol) upon admission. There were several scars caused by chronic ulcers adjacent to the lesion . She denied any history of neoplasms.\nThe lesion was resected under local anesthesia. The sample was fixed in 4 % buffered formalin and embedded in paraffin using conventional techniques. Serial tissue sections were studied using hematoxylin and eosin staining, histochemistry, immunohistochemistry , and HPV type-specific PCR and genotyping. Blind evaluation of all results was performed by two independent pathologists.\nLight microscopy examination showed that the lesion was mainly composed of malignant clear cells and signet-ring cells arranged in thick trabeculae or solid nests . The clear cells contained prominent vacuoles which were sharply demarcated and appeared empty. Each of the signet-ring cells contained a large cytoplasmic vacuole and an eccentric nucleus . Atypical mitotic figures were plentiful.\nPeriodic-acid Schiff (PAS), Alcian blue (AB), and mucicarmin techniques were employed to explore the nature of the observed clear cell/signet ring cell structures. The septa rather than the vacuoles showed positivity for PAS indicating the existence of glycogen . However, neither septa nor vacuoles expressed AB or mucicarmine, suggesting that neither mucin nor mucopolysaccharides existed (data not shown). In line with the above results, the septa expressed cytokeratin AE1/AE3, CK5/6, CK14, and CK19 . CK5/6 is a high molecular weight cytokeratin wihic is usually up-regulated in neoplasms of epithelial origin, including cSCC. Although malignant cells did not express mutant p53, they displayed strong and diffuse positivity for p63, another member of the p53 family playing an important role in normal epithelial development and differentiation . We also found the increased expression of fibroblast growth factor receptor-2 (FGFR2), a downstream effector of p63 . Nucleus immunoreactivity for Ki-67 is a hallmark of high cell proliferation. In the sections, less than 5 % of cancer cells expressed Ki-67 . Malignant cells exhibited negativity for CK7, CK8, CK18, CK20, P16, and c-erbB-2 (data not shown).\nDNA was extracted from FFPE tissue sections and purified using the TIANamp FFPE DNA Kit (TIANGEN, Beijing, China). The operation was performed according to the manufacturer’s protocol. Subsequently, HPV DNA was amplified with the L1 consensus HPV PGMY09/PGMY11 primer set as described previously . PCR was performed with a 25 ul reaction system, which contained 1 ul (89 ng) DNA template and 0.75 ul DNA Taq polymerase. Amplification was carried out for 40 cycles in the CFX96 TouchTM Real-Time PCR Detection System (BIO-RAD, USA). HPV genotyping was performed using the HPV GenoArray test kit (Hybribio, Chaozhou, China), which identifies 15 high-risk HPV types (HPV type 16, 18, 31, 33, 35, 39, 45, 51, 52, 53, 56, 58, 59, 66, and 68) and 6 low-risk HPV types (HPV type 6, 11, 42, 43, 44, and 81) using flow-through hybridization and gene chips. The result of genotyping indicated that this patient was not infected with HPV .", + "fulltext_subclaims": [ + "The patient is a 78-year-old Chinese woman.", + "The patient had a 2-week history of a mushroom-like lump in her right thigh.", + "The lump measured 5 × 3 × 1.5 cm.", + "The patient had a 30-year history of type 2 diabetes mellitus.", + "The patient's HbA1c was 8.4% (68 mMol/mol) upon admission.", + "There were several scars caused by chronic ulcers adjacent to the lesion.", + "The lesion was resected under local anesthesia.", + "The sample was fixed in 4% buffered formalin.", + "Serial tissue sections were studied using hematoxylin and eosin staining.", + "The lesion was mainly composed of malignant clear cells and signet-ring cells.", + "The clear cells contained prominent vacuoles which were sharply demarcated and appeared empty.", + "Each of the signet-ring cells contained a large cytoplasmic vacuole and an eccentric nucleus.", + "Atypical mitotic figures were plentiful.", + "Periodic-acid Schiff (PAS) was used to explore the nature of the observed clear cell/signet ring cell structures.", + "The septa rather than the vacuoles showed positivity for PAS.", + "The septa expressed cytokeratin AE1/AE3, CK5/6, CK14, and CK19.", + "Malignant cells did not express mutant p53.", + "Malignant cells displayed strong and diffuse positivity for p63.", + "Malignant cells exhibited negativity for CK7, CK8, CK18, CK20, P16, and c-erbB-2.", + "Less than 5% of cancer cells expressed Ki-67.", + "DNA was extracted from FFPE tissue sections.", + "HPV DNA was amplified with the L1 consensus HPV PGMY09/PGMY11 primer set.", + "The result of genotyping indicated that this patient was not infected with HPV." + ], + "summary": "A 78-year-old Chinese woman with type 2 DM presented with a mushroom-like lump in her right thigh. Histological findings revealed that the lesion was mainly composed of clear cells and signet-ring cells. The septa of vacuoles in cytoplasm displayed positivity for periodic acid schiff (PAS) and cytokeratins such as AE1/AE3, CK5/6, CK14, and CK19. Malignant cells did not express CK7, CK8, CK18, CK20, p16, p53, or c-erbB-2, and the Ki-67 index was less than 5 %. We further explored the etiology of clear cell/signet-ring cell cSCC using human papillomavirus (HPV) type-specific PCR and genotyping and confirmed that the patient was not infected with HPV. Nucleus positivity for p63 indicated the involvement of the p53 family in the lesion. Meanwhile, the expression of fibroblast growth factor receptor-2 (FGFR2), a downstream effector of p63, was upregulated in tumor cells.", + "summary_subclaims": [ + "The patient is a 78-year-old Chinese woman.", + "The patient has type 2 diabetes mellitus.", + "The patient had a mushroom-like lump in her right thigh.", + "Histological findings revealed the lesion was mainly composed of clear cells and signet-ring cells.", + "The septa of vacuoles in cytoplasm displayed positivity for periodic acid schiff (PAS).", + "The septa of vacuoles in cytoplasm displayed positivity for AE1/AE3.", + "The septa of vacuoles in cytoplasm displayed positivity for CK5/6.", + "The septa of vacuoles in cytoplasm displayed positivity for CK14.", + "The septa of vacuoles in cytoplasm displayed positivity for CK19.", + "Malignant cells did not express CK7.", + "Malignant cells did not express CK8.", + "Malignant cells did not express CK18.", + "Malignant cells did not express CK20.", + "Malignant cells did not express p16.", + "Malignant cells did not express p53.", + "Malignant cells did not express c-erbB-2.", + "The Ki-67 index was less than 5%.", + "HPV type-specific PCR and genotyping were used to explore the etiology of clear cell/signet-ring cell cSCC.", + "The patient was not infected with HPV.", + "Nucleus positivity for p63 indicated the involvement of the p53 family in the lesion.", + "Fibroblast growth factor receptor-2 (FGFR2) was upregulated in tumor cells." + ] + }, + { + "id": "multiclinsum_test_1385_en.txt", + "fulltext": "A 38-year-old male presented to our emergency room with a 4-day history of intermittent fever and chills without nausea or vomiting. The patient had a past history of intravenous heroin abuse and atrioventricular reentry tachycardia status post radiofrequency catheter ablation. Shortness of breath, cough with some yellowish sputum, tachycardia, low blood pressure (80/40 mmHg under Levophed use), and anuria were noted. The patient had not experienced nausea or vomiting.\nPhysical examination revealed bilateral coarse breath sounds and a 4/6 pan systolic heart murmur over the left fourth rib. Laboratory analysis revealed a white blood cell count of 35,030 μL (range: 3500–9100 μL; neutrophilia, 73.4%) and a creatinine level of 3.19 mg/dL (range: 0.70–1.30 mg/dL). Chest X-ray revealed interstitial infiltration with mottled consolidation superimposed on bilateral lung fields and blunting of the left costophrenic angle. Chest computerized tomography (CT) showed loculated pleural effusion, consolidations with central lucency collection in both lungs, and mild pericardial effusion . Echocardiography revealed normal left ventricle wall motion (left ventricular ejection fraction, 58%) and a floating vegetation in the tricuspid valve with moderate to severe tricuspid regurgitation.\nBecause left empyema and tricuspid valve IE with septic or cardiogenic shock were suspected, left chest tube were inserted and left pleura effusion culture showed methicillin-susceptible S. aureus. Right heart failure secondary to severe TR and poor response to medical therapy were noted 1 day after chest tube insertion. An endotracheal tube was insert ion and the patient underwent tricuspid valve replacement with a 33 mm Hancock II tissue valve via median sternotomy with another left chest tube insertion due to all of the anterior chordae tendineae were rupture. The pre-operative transesophageal echocardiography (TEE) showed 0.9 × 1.2 cm2 vegetation over tricuspid valve. .\nBlood and sputum cultures showed methicillin-susceptible S. aureus. The patient received postoperative antibiotic treatment (oxacillin, 2000 mg six times daily). The early postoperative treatment course was uneventful, with white blood cell count decreased to 14,300 μL and creatinine level decreased to 1.08 mg/dL.\nHowever, fever up to 38.4 °C and dyspnea were noted on postoperative day 14. Follow up chest X-ray revealed loculated bilateral pleural effusions with perihilar and lower lung haziness infiltrates . Chest CT revealed multiple cavitary nodules in the bilateral lungs . The patient underwent thoracoscopic decortication of the right pleura and incision of the right lower lung abscess with postoperative chest tube drainage. Intraoperative pleural fluid and lung abscess cultures showed carbapenem-susceptible A. baumannii complex and C. albicans. We replaced oxacillin with meropenem 500 mg four times daily and fluconazole 200 mg one time daily. No further fever was noted. After 4 weeks of antibiotic treatment, chest X-ray revealed bilateral clear lung markings with only mild blunting of the right costophrenic angle.", + "fulltext_subclaims": [ + "The patient was a 38-year-old male.", + "The patient had a 4-day history of intermittent fever and chills.", + "The patient had no nausea or vomiting.", + "The patient had a past history of intravenous heroin abuse.", + "The patient had a past history of atrioventricular reentry tachycardia.", + "The patient had atrioventricular reentry tachycardia status post radiofrequency catheter ablation.", + "The patient had shortness of breath.", + "The patient had cough with some yellowish sputum.", + "The patient had tachycardia.", + "The patient had low blood pressure (80/40 mmHg under Levophed use).", + "The patient had anuria.", + "Physical examination revealed bilateral coarse breath sounds.", + "Physical examination revealed a 4/6 pan systolic heart murmur over the left fourth rib.", + "Laboratory analysis revealed a white blood cell count of 35,030 μL.", + "The white blood cell count range was 3500–9100 μL.", + "The white blood cell count showed neutrophilia, 73.4%.", + "Laboratory analysis revealed a creatinine level of 3.19 mg/dL.", + "The creatinine level range was 0.70–1.30 mg/dL.", + "Chest X-ray revealed interstitial infiltration with mottled consolidation superimposed on bilateral lung fields.", + "Chest X-ray showed blunting of the left costophrenic angle.", + "Chest CT showed loculated pleural effusion.", + "Chest CT showed consolidations with central lucency collection in both lungs.", + "Chest CT showed mild pericardial effusion.", + "Echocardiography revealed normal left ventricle wall motion.", + "Echocardiography showed a floating vegetation in the tricuspid valve.", + "Echocardiography showed moderate to severe tricuspid regurgitation.", + "Left chest tube was inserted.", + "Left pleura effusion culture showed methicillin-susceptible S. aureus.", + "Right heart failure secondary to severe TR was noted.", + "An endotracheal tube was inserted.", + "The patient underwent tricuspid valve replacement with a 33 mm Hancock II tissue valve via median sternotomy.", + "Another left chest tube was inserted due to all of the anterior chordae tendineae being ruptured.", + "The pre-operative TEE showed 0.9 × 1.2 cm2 vegetation over the tricuspid valve.", + "Blood and sputum cultures showed methicillin-susceptible S. aureus.", + "The patient received postoperative antibiotic treatment with oxacillin, 2000 mg six times daily.", + "The early postoperative treatment course was uneventful.", + "The white blood cell count decreased to 14,300 μL.", + "The creatinine level decreased to 1.08 mg/dL.", + "Fever up to 38.4 °C was noted on postoperative day 14.", + "Dyspnea was noted on postoperative day 14.", + "Follow-up chest X-ray revealed loculated bilateral pleural effusions.", + "Follow-up chest X-ray showed perihilar and lower lung haziness infiltrates.", + "Chest CT revealed multiple cavitary nodules in the bilateral lungs.", + "The patient underwent thoracoscopic decortication of the right pleura.", + "The patient underwent incision of the right lower lung abscess.", + "Postoperative chest tube drainage was performed.", + "Intraoperative pleural fluid and lung abscess cultures showed carbapenem-susceptible A. baumannii complex.", + "Intraoperative pleural fluid and lung abscess cultures showed C. albicans.", + "Oxacillin was replaced with meropenem 500 mg four times daily.", + "Fluconazole 200 mg one time daily was added.", + "No further fever was noted.", + "After 4 weeks of antibiotic treatment, chest X-ray revealed bilateral clear lung markings.", + "After 4 weeks of antibiotic treatment, chest X-ray showed only mild blunting of the right costophrenic angle." + ], + "summary": "We report the case of a 38-year-old male (an intravenous drug abuser) diagnosed with tricuspid valve IE who underwent tricuspid valve replacement. The case was complicated by multiple lung abscesses and thoracic empyema. The pathogens causing the lung abscesses and empyema were Acinetobacter baumannii complex and Candida albicans, which were different from those causing the endocarditis. After 4 weeks of antibiotic treatment, chest X-ray revealed bilateral clear lung markings with only mild blunting of the right costophrenic angle.", + "summary_subclaims": [ + "The patient was a 38-year-old male.", + "The patient was an intravenous drug abuser.", + "The patient was diagnosed with tricuspid valve IE.", + "The patient underwent tricuspid valve replacement.", + "The case was complicated by multiple lung abscesses.", + "The case was complicated by thoracic empyema.", + "The pathogens causing the lung abscesses and empyema were Acinetobacter baumannii complex and Candida albicans.", + "The pathogens causing the lung abscesses and empyema were different from those causing the endocarditis.", + "After 4 weeks of antibiotic treatment, chest X-ray revealed bilateral clear lung markings.", + "After 4 weeks of antibiotic treatment, chest X-ray showed only mild blunting of the right costophrenic angle." + ] + }, + { + "id": "multiclinsum_test_3366_en.txt", + "fulltext": "A 76-year-old male complained with shortness of breath, systemic edema for one month. He had been diagnosed as “multiple peripheral neuropathy” in several hospitals due to progressive numbness, pain and weakness of limbs, sweating, constipation and unexplained weight loss for 7 years. He had a history of hypertension for 13 years, but his blood pressure is normal without therapy in the recent two years. The patient had no history of diabetes, smoking, alcohol over consumption in the past. His father had a history of limb numbness and systemic edema. The patient had no other family history of genetic diseases.\n\nOn physical examination, malnourished, anemic, lethargic, limb muscle weakness, decreased muscle tone, weakened tendon reflex, sacroiliac decubital necrosis and severe edema.\n\nLaboratory tests revealed myocardial damage with persistent elevation of hs-TnI and NT-proBNP, neutrophilic leukocytosis, moderate anemia with decrease in erythrocytes and hematocrit, mild hypoxemia. Furthermore, other abnormal parameters are listed in Table 1. Chest X-ray showed bilateral pulmonary inflammation with pleural effusion. Electrocardiogram (ECG) indicated low QRS voltage of limb leads, abnormal Q wave of II, III and aVF, and poor increase of V1-V6 R wave. Echocardiography revealed cardiac hypertrophy, left ventricular diastolic dysfunction (grade II) and small amount of pericardial effusion. There was discordance between the low QRS voltage and left ventricular hypertrophy, which may be a vital clue to the diagnosis of cardiac amyloidosis (CA). The speckle tracking imaging showed reduced global longitudinal strain (GLS) with apical sparing and with an apical-to-basal strain ratio 2.7 and the ejection fraction (EF) to GLS ratio (EFSR) was 4.4, which were consistent with the ultrasonic characteristics of CA. A thorough diagnostic approach was followed, in order to detect the underlying pathological condition. Several computed tomography (CT) scans of the chest showed diffuse pulmonary interstitial changes, cystic changes and shadows of lung consolidation, gradually increased shadow of small calcification on the lung surface at the bottom of both lungs, which were typical manifestations of pulmonary amyloid deposition. Whether there is pulmonary inflammation and infection needs to be determined in combination with blood cell examination and C-reactive protein level. The CMR and nuclear medicine modalities (PYP) were not performed because of his critical condition.\n\nFor the differential diagnosis between hereditary transthyretin cardiac amyloidosis and AL amyloidosis, this patient had three serum-free light chain assays and immunofixation electrophoresis. The first results were that Fκ and Fλ were 3.05 g/L (normal range: 3.3~19.4mg/L) and 1.37g/L (normal range: 5.7 ~ 26.3 mg/L), respectively. The second result was that elevated free light chain κ (90.9 mg/L, normal range: 3.3~19.4mg/L)) and free light chain λ (62.2 mg/L, normal range: 5.7 ~ 26.3 mg/L), and Fκ/Fλ ratio was 1.46 (normal range: 0.26~1.65). The third results were elevated free light chain κ (124.78 mg/L, normal range: 3.3~19.4mg/L) and free light chain λ (74.10mg/L, normal range: 5.7 ~ 26.3 mg/L), and Fκ/Fλ ratio was 1.68 (normal range: 0.26~1.65). Serum immunofixation electrophoresis was negative for the patient, and serum-free light chain Fκ/Fλ ratio is normal or close to normal (0.26–1.65), so AL amyloidosis can be excluded.1\n\nAbdominal subcutaneous fat biopsy was negative, and no other tissue biopsy was done because of his critical condition. Although the patient is an elderly male, we did not consider the patient as senile wild-type amyloid transthyretin (wtATTR) amyloidosis and insisted on TTR genetic sequencing because the latter generally does not cause progressive polyneuropathy and autonomic dysfunction. A missense mutation c. 148 G-A (p. V50M, Val30Met) was detected in TTR genetic sequencing. It is the pathological mutation site of patients with hereditary amyloid transthyretin (hATTR) amyloidosis.\n\nThe genetic finding confirmed late-onset transthyretin Val30Met-associated hereditary amyloid transthyretin (hATTR) amyloidosis, familial amyloid polyneuropathy (FAP) and cardiac amyloidosis (CA) for the patient. Recently, the patient’s first son developed limb numbness and found the same TTR gene abnormality.\n\nThe patient had received doxycycline + ursodeoxycholic acid, tafamidis (chlorobenzoic acid, a stable TTR tetramer). The patient had intractable intestinal obstruction on 7 days after treatment, and had to stop taking the medicine. After 80 days of treatment, the patient tragically died of cardiac involvement. We did not perform a biopsy of the heart and lung on autopsy to confirm ATTR amyloidosis deposits because the patient’s son refused.", + "fulltext_subclaims": [ + "The patient is a 76-year-old male.", + "The patient complained of shortness of breath.", + "The patient had systemic edema for one month.", + "The patient had progressive numbness, pain, and weakness of limbs for 7 years.", + "The patient had been diagnosed with multiple peripheral neuropathy in several hospitals.", + "The patient had a history of hypertension for 13 years.", + "The patient’s blood pressure is normal without therapy in the recent two years.", + "The patient had no history of diabetes.", + "The patient had no history of smoking.", + "The patient’s father had a history of limb numbness.", + "The patient’s father had a history of systemic edema.", + "On physical examination, the patient was malnourished.", + "On physical examination, the patient was anemic.", + "On physical examination, the patient was lethargic.", + "On physical examination, there was limb muscle weakness.", + "On physical examination, there was decreased muscle tone.", + "On physical examination, there was weakened tendon reflex.", + "On physical examination, there was sacroiliac decubital necrosis.", + "On physical examination, there was severe edema.", + "Laboratory tests revealed persistent elevation of hs-TnI.", + "Laboratory tests revealed persistent elevation of NT-proBNP.", + "Laboratory tests showed neutrophilic leukocytosis.", + "Laboratory tests showed moderate anemia with decrease in erythrocytes.", + "Laboratory tests showed moderate anemia with decrease in hematocrit.", + "Laboratory tests showed mild hypoxemia.", + "Chest X-ray showed bilateral pulmonary inflammation.", + "Chest X-ray showed pleural effusion.", + "ECG indicated low QRS voltage of limb leads.", + "ECG showed abnormal Q wave of II, III, and aVF.", + "ECG showed poor increase of V1-V6 R wave.", + "Echocardiography revealed cardiac hypertrophy.", + "Echocardiography showed left ventricular diastolic dysfunction (grade II).", + "Echocardiography showed small amount of pericardial effusion.", + "There was discordance between the low QRS voltage and left ventricular hypertrophy.", + "The discordance may be a vital clue to the diagnosis of cardiac amyloidosis.", + "Speckle tracking imaging showed reduced global longitudinal strain (GLS) with apical sparing.", + "The apical-to-basal strain ratio was 2.7.", + "The ejection fraction (EF) to GLS ratio (EFSR) was 4.4.", + "The EFSR was consistent with the ultrasonic characteristics of cardiac amyloidosis.", + "CT scans showed diffuse pulmonary interstitial changes.", + "CT scans showed cystic changes.", + "CT scans showed shadows of lung consolidation.", + "CT scans showed small calcification on the lung surface at the bottom of both lungs.", + "The small calcification was typical of pulmonary amyloid deposition.", + "Whether there is pulmonary inflammation and infection needs to be determined.", + "CMR and nuclear medicine modalities (PYP) were not performed.", + "The patient had three serum-free light chain assays.", + "The first serum-free light chain assay showed Fκ 3.05 g/L.", + "The first serum-free light chain assay showed Fλ 1.37 g/L.", + "The second serum-free light chain assay showed elevated free light chain κ (90.9 mg/L).", + "The second serum-free light chain assay showed elevated free light chain λ (62.2 mg/L).", + "The second serum-free light chain assay showed Fκ/Fλ ratio 1.46.", + "The third serum-free light chain assay showed elevated free light chain κ (124.78 mg/L).", + "The third serum-free light chain assay showed elevated free light chain λ (74.10 mg/L).", + "The third serum-free light chain assay showed Fκ/Fλ ratio 1.68.", + "Serum immunofixation electrophoresis was negative.", + "Serum-free light chain Fκ/Fλ ratio is normal or close to normal.", + "AL amyloidosis can be excluded.", + "Abdominal subcutaneous fat biopsy was negative.", + "No other tissue biopsy was done.", + "The patient is an elderly male.", + "The patient did not have progressive polyneuropathy.", + "The patient did not have autonomic dysfunction.", + "TTR genetic sequencing was performed.", + "A missense mutation c.148 G-A (p. V50M, Val30Met) was detected.", + "The mutation is the pathological mutation site of patients with hereditary amyloid transthyretin (hATTR) amyloidosis.", + "The genetic finding confirmed late-onset transthyretin Val30Met-associated hATTR amyloidosis.", + "The genetic finding confirmed familial amyloid polyneuropathy (FAP).", + "The genetic finding confirmed cardiac amyloidosis (CA).", + "The patient’s first son developed limb numbness.", + "The patient’s first son found the same TTR gene abnormality.", + "The patient received doxycycline + ursodeoxycholic acid.", + "The patient received tafamidis.", + "The patient had intractable intestinal obstruction 7 days after treatment.", + "The patient had to stop taking the medicine.", + "After 80 days of treatment, the patient died of cardiac involvement.", + "A biopsy of the heart and lung was not performed on autopsy.", + "The patient’s son refused the biopsy." + ], + "summary": "A 76-year-old male patient presented with progressive numbness, pain and weakness in his limbs, sweating, constipation and unexplained weight loss over the past seven years. He has shortness of breath, edema and hypotension for one month. The low QRS voltage on limb leads was not consistent with left ventricular hypertrophy, which is an important clue of cardiac amyloidosis (CA). The results of echocardiography speckle tracking imaging were consistent with CA. Serum immunofixation electrophoresis was negative, and serum-free light chain Fκ/Fλ ratio is normal or close to normal (0.26-1.65) for the patient, so AL amyloidosis can be excluded. A missense mutation c. 148 G-A Val30Met (p.Val50Met) was detected in TTR gene sequencing. The genetic finding confirmed hATTR Val30Met, familial amyloid polyneuropathy (FAP) and CA for the patient. The treatment effect was poor, and he died of cardiac involvement.", + "summary_subclaims": [ + "The patient is a 76-year-old male.", + "The patient had progressive numbness, pain and weakness in his limbs.", + "The patient had sweating, constipation and unexplained weight loss over the past seven years.", + "The patient had shortness of breath, edema and hypotension for one month.", + "The low QRS voltage on limb leads was not consistent with left ventricular hypertrophy.", + "The low QRS voltage on limb leads was an important clue of cardiac amyloidosis.", + "The results of echocardiography speckle tracking imaging were consistent with cardiac amyloidosis.", + "Serum immunofixation electrophoresis was negative.", + "The serum-free light chain Fκ/Fλ ratio was normal or close to normal (0.26-1.65).", + "AL amyloidosis can be excluded.", + "A missense mutation c. 148 G-A Val30Met (p.Val50Met) was detected in TTR gene sequencing.", + "The genetic finding confirmed hATTR Val30Met.", + "The genetic finding confirmed familial amyloid polyneuropathy.", + "The genetic finding confirmed cardiac amyloidosis.", + "The treatment effect was poor.", + "The patient died of cardiac involvement." + ] + }, + { + "id": "multiclinsum_test_352_en.txt", + "fulltext": "A 41-year-old woman, 4 gravida, 2 para, 2 Abortions with a history of C-section delivery. The patient presented with dysuria, pollakiuria, pelvic heaviness and an episode of acute urinary retention. Physical examination revealed a solid, well limited and fixed mass on the anterior vaginal wall. Pelvic ultrasound revealed a heterogeneous inter vesico-vaginal mass measuring 60/40 mm. MRI showed a pedicled inter vesico-vaginal mass (60/48/38 mm), isointense on T1, a heterogeneous signal on T2 with several cystic zones taking contrast in an early and intense rate suggesting cervical leiomyoma. The Surgical evaluation was recommended by the vaginal route due to the location of the mass. A midline incision was carried in the anterior vaginal wall, 2 cm below the urethral meatus. Mass resection was performed in two fragments, after adhesiolysis, which was difficult because of adhesion to the bladder, urethra and vaginal wall. A bladder breach was identified after resection of the mass and was immediately sutured. The removed tissue was a round, firm, 80/50/40 mm, gray tumor. Histopathology examination of the specimen showed that it was a focal endometriosis . The urinary catheter was removed after 1 week. There were no postoperative complications.", + "fulltext_subclaims": [ + "The patient is a 41-year-old woman.", + "The patient is 4 gravida, 2 para, 2 Abortions.", + "The patient has a history of C-section delivery.", + "The patient presented with dysuria.", + "The patient presented with pollakiuria.", + "The patient presented with pelvic heaviness.", + "The patient had an episode of acute urinary retention.", + "Physical examination revealed a solid, well limited and fixed mass on the anterior vaginal wall.", + "Pelvic ultrasound revealed a heterogeneous inter vesico-vaginal mass measuring 60/40 mm.", + "MRI showed a pedicled inter vesico-vaginal mass (60/48/38 mm).", + "MRI showed the mass was isointense on T1.", + "MRI showed the mass had a heterogeneous signal on T2 with several cystic zones taking contrast in an early and intense rate.", + "The mass was suggested to be cervical leiomyoma.", + "Surgical evaluation was recommended by the vaginal route.", + "A midline incision was carried in the anterior vaginal wall, 2 cm below the urethral meatus.", + "Mass resection was performed in two fragments.", + "Adhesiolysis was difficult because of adhesion to the bladder, urethra and vaginal wall.", + "A bladder breach was identified after resection of the mass.", + "The bladder breach was immediately sutured.", + "The removed tissue was a round, firm, 80/50/40 mm, gray tumor.", + "Histopathology examination of the specimen showed it was focal endometriosis.", + "The urinary catheter was removed after 1 week.", + "There were no postoperative complications." + ], + "summary": "A 41-year-old female was presented with urinary symptoms. There was history of caesarean section. Physical examination revealed an anterior vaginal wall mass. Pelvic MRI showed an inter vesico-vaginal mass, suggesting a leiomyoma. Surgical excision was performed by the vaginal route. There were no postoperative complications. Histopathology examination showed focal endometriosis.", + "summary_subclaims": [ + "The patient was a 41-year-old female.", + "The patient was presented with urinary symptoms.", + "There was history of caesarean section.", + "Physical examination revealed an anterior vaginal wall mass.", + "Pelvic MRI showed an inter vesico-vaginal mass.", + "Pelvic MRI suggested a leiomyoma.", + "Surgical excision was performed by the vaginal route.", + "There were no postoperative complications.", + "Histopathology examination showed focal endometriosis." + ] + }, + { + "id": "multiclinsum_test_623_en.txt", + "fulltext": "A 13-year-old child with learning disability was referred for ophthalmic assessment as she complained of bilateral blurring of vision. At presentation, her visual acuity was 1/60 in the right eye and 6/18 in the left eye. Relative afferent pupillary defect (RAPD) was present in the right eye. Both eyes anterior segment examination findings were normal. Grade 1 vitritis was noted in the right eye. Funduscopic examination of the right eye revealed a pale optic disc and pigmented scar over the macula with salt and pepper appearance. Intense retinitis with focal areas of haemorrhage was present nasally . There was mild pallor of the left optic disc with macula and peripheral granular retinitis .\nSystematically, she was diagnosed with combined T and B cell deficiencies by the immunologist at the age of 11. At that time, she presented with high fever, recurrent episodes of diarrhoea, oral thrush, and failure to thrive, with the weight of only 12kg. PIDD screening showed low T cell, very low B cell counts, and low immunoglobulin levels . Her systemic therapy consisted of 3 weekly intravenous immunoglobulin, sulfamethoxazole, and trimethoprim prophylaxis as well as empirical therapy for fungal infection which include syrup fluconazole 6mg/kg/day and syrup nystatin 1ml QID. She was also treated for CMV colitis as HPE of the colon showed CMV inclusion bodies. She completed 6 weeks of intravenous ganciclovir 3 months prior to presentation of her ophthalmic symptoms.\nWe diagnosed the child of having bilateral eye CMV retinitis based on typical fundus features and history of treated CMV colitis. She was planned for right eye intravitreal ganciclovir injection in view of poor visual function with posterior pole involvement. However, she was deemed unfit to undergo general anaesthesia due to concomitant hospital acquired pneumonia. IV ganciclovir 75mg (6mg/kg) 12 hourly was started and good response was noted after 2 weeks of therapy . The treatment was continued for 8 weeks until the retinitis lesions had healed with scarring . However, the right visual acuity reduced to light perception and improved to 6/9 in the left eye.", + "fulltext_subclaims": [ + "A 13-year-old child with learning disability was referred for ophthalmic assessment.", + "She complained of bilateral blurring of vision.", + "Her visual acuity was 1/60 in the right eye.", + "Her visual acuity was 6/18 in the left eye.", + "Relative afferent pupillary defect (RAPD) was present in the right eye.", + "Both eyes anterior segment examination findings were normal.", + "Grade 1 vitritis was noted in the right eye.", + "Funduscopic examination of the right eye revealed a pale optic disc.", + "Funduscopic examination of the right eye revealed a pigmented scar over the macula with salt and pepper appearance.", + "Intense retinitis with focal areas of haemorrhage was present nasally.", + "There was mild pallor of the left optic disc.", + "There was macula and peripheral granular retinitis.", + "She was diagnosed with combined T and B cell deficiencies at the age of 11.", + "PIDD screening showed low T cell counts.", + "PIDD screening showed very low B cell counts.", + "PIDD screening showed low immunoglobulin levels.", + "Her systemic therapy consisted of 3 weekly intravenous immunoglobulin.", + "Her systemic therapy included sulfamethoxazole and trimethoprim prophylaxis.", + "Her systemic therapy included empirical therapy for fungal infection.", + "Empirical therapy for fungal infection included syrup fluconazole 6mg/kg/day.", + "Empirical therapy for fungal infection included syrup nystatin 1ml QID.", + "She was treated for CMV colitis as HPE of the colon showed CMV inclusion bodies.", + "She completed 6 weeks of intravenous ganciclovir 3 months prior to presentation of her ophthalmic symptoms.", + "We diagnosed the child of having bilateral eye CMV retinitis based on typical fundus features and history of treated CMV colitis.", + "She was planned for right eye intravitreal ganciclovir injection.", + "She was deemed unfit to undergo general anaesthesia due to concomitant hospital acquired pneumonia.", + "IV ganciclovir 75mg (6mg/kg) 12 hourly was started.", + "Good response was noted after 2 weeks of therapy.", + "The treatment was continued for 8 weeks until the retinitis lesions had healed with scarring.", + "The right visual acuity reduced to light perception.", + "The left visual acuity improved to 6/9." + ], + "summary": "13-year-old child with combined T and B cell deficiencies was diagnosed of bilateral zone 1 CMV retinitis. Intravitreal injections were unable to be given in a regular and timely manner under general anaesthesia due to her underlying systemic disease. The child was treated with intravenous ganciclovir for 8 weeks until eventual resolution of the retinitis. However, visual acuity deteriorated due to progressive optic nerve involvement.", + "summary_subclaims": [ + "The patient was a 13-year-old child with combined T and B cell deficiencies.", + "The patient was diagnosed of bilateral zone 1 CMV retinitis.", + "Intravitreal injections were unable to be given in a regular and timely manner under general anaesthesia due to her underlying systemic disease.", + "The child was treated with intravenous ganciclovir for 8 weeks.", + "The retinitis eventually resolved.", + "Visual acuity deteriorated due to progressive optic nerve involvement." + ] + }, + { + "id": "multiclinsum_test_861_en.txt", + "fulltext": "A 32-year-old male presented to the outpatient division of our hospital with coughing and a slight fever. He had a history of aortic valve stenosis (bicuspid valve) and reduced LV ejection fraction (EF, 40%) at the age of 5 years. He had received an operation of aortic valve replacement at the age of 16 years. After surgery, he was followed up by another hospital and was given warfarin with fair control. At room temperature, the patient’s physical parameters were as follows: temperature, 37.0°C; blood pressure, 90/60 mmHg; pulse, 89 beats/min; and oxygen saturation, 99% (room air). Auscultation revealed normal breath sounds. A grade II/VI systolic ejection murmur was noted at the right sternal border. A chest radiograph revealed marked cardiomegaly and mediastinum expansion without a difference of increased radiolucency between the left and right lungs. A chest computed tomography (CT) scan revealed a 10-cm aneurysm in the ascending aorta . The CT image indicated that the TAA had compressed the right pulmonary artery without any difference of contrast medium character between left and right lung, indicating that the right pulmonary artery blood flow was not disturbed. An echocardiogram showed left ventricular (LV) enlargement (LV end-diastolic diameter, 57 mm) and diffuse LV hypokinesis (EF, 35%). A Doppler echocardiogram showed a trans-aortic valve pressure gradient of 18 mmHg. However, his exercise tolerance was well. Any dyspnea on effort had not seen during out-patient clinic (NYHA I). Ventilation/perfusion lung scintigraphy was conducted to exclude aneurysm-induced compression of surrounding organs, but no significant findings were observed. The patient had never complained of dyspnea during nighttime in the supine position either.\nA total aortic arch replacement was planned. However, after intravenous anesthesia (his body weight 78 kg, 5-mg midazolam, 100-mg thiopental and a total of 90-mg rocuronium) and intubation in the supine position, his oxygen saturation (70%) and blood pressure (60/40 mmHg) decreased rapidly. His arterial gas analysis showed the following results on FiO2 100%: pH, 7.234; PaO2, 20 mmHg; PaCO2, 72.6 mmHg; SaO2, 18.6% and HCO3–, 29.6 mmol/L. Cardiopulmonary collapse was resistant to vasopressors (total 12-mg ephedrine) and high oxygenation. As acute pulmonary embolism was tentatively considered in this patient, pulmonary arteriography was immediately performed. The left pulmonary artery was patent. However the right pulmonary artery was totally defected. Swan–Ganz catheter was unable to pass the main branch of the right pulmonary artery. Additionally, because of the absence of breath sounds on auscultation in the left lung field, bronchoscopy was performed and complete compression of the left main bronchus was noted . We finally diagnosed sudden hemodynamic collapse and hypoxia as simultaneous compression of both right pulmonary artery and left main bronchus.\nPercutaneous cardiopulmonary support (PCPS) was conducted resulting in recover from the cardiopulmonary collapse effectively. We discontinued the operation and transferred the patient to the intensive care unit. After the patient regained consciousness from anesthesia, his hemodynamic collapse was gradually improved, and weaning of PCPS was achieved without use of inotropes. Besides, bronchoscopy revealed that occlusion of the left main bronchus disappeared, and he was successfully extubated. Fortunately, he recovered the next day without neurological deficit. At the second surgery, PCPS was initiated with local anesthesia before general anesthesia and intubation. We denuded the right femoral vein and artery, and introduced cannulas for PCPS. General anesthesia was conducted carefully. We also performed bronchoscopy after intubation and found out that the left main bronchus was almost occluded in much the same way as the prior operation. However, his oxygen saturation was not decreased. At this time, PCPS was thought to be useful to prevent from hypoxia and hemodynamic collapse. The aortic valve prosthesis that previously replaced was completely intact. The aortic aneurysm occupied from just above the prosthesis to the distal aortic arch. We successfully performed total arch replacement and reconstruction of bilateral coronary arteries, brachiocephalic artery, left common carotid artery and left subclavian artery without any adverse events .", + "fulltext_subclaims": [ + "The patient was a 32-year-old male.", + "He presented with coughing and a slight fever.", + "He had a history of aortic valve stenosis (bicuspid valve).", + "He had reduced LV ejection fraction (EF, 40%) at the age of 5 years.", + "He had received an operation of aortic valve replacement at the age of 16 years.", + "After surgery, he was followed up by another hospital.", + "He was given warfarin with fair control.", + "The patient’s temperature was 37.0°C.", + "The patient’s blood pressure was 90/60 mmHg.", + "The patient’s pulse was 89 beats/min.", + "The patient’s oxygen saturation was 99% (room air).", + "A grade II/VI systolic ejection murmur was noted at the right sternal border.", + "A chest radiograph revealed marked cardiomegaly.", + "A chest radiograph showed mediastinum expansion.", + "A chest computed tomography (CT) scan revealed a 10-cm aneurysm in the ascending aorta.", + "The CT image indicated that the TAA had compressed the right pulmonary artery.", + "An echocardiogram showed left ventricular (LV) enlargement (LV end-diastolic diameter, 57 mm).", + "An echocardiogram showed diffuse LV hypokinesis (EF, 35%).", + "A Doppler echocardiogram showed a trans-aortic valve pressure gradient of 18 mmHg.", + "The patient had no dyspnea on effort during out-patient clinic (NYHA I).", + "Ventilation/perfusion lung scintigraphy was conducted.", + "No significant findings were observed on ventilation/perfusion lung scintigraphy.", + "The patient had never complained of dyspnea during nighttime in the supine position.", + "A total aortic arch replacement was planned.", + "After intravenous anesthesia, his oxygen saturation decreased rapidly.", + "His oxygen saturation was 70%.", + "His blood pressure was 60/40 mmHg.", + "His arterial gas analysis showed pH 7.234.", + "His arterial gas analysis showed PaO2 20 mmHg.", + "His arterial gas analysis showed PaCO2 72.6 mmHg.", + "His arterial gas analysis showed SaO2 18.6%.", + "His arterial gas analysis showed HCO3– 29.6 mmol/L.", + "Cardiopulmonary collapse was resistant to vasopressors.", + "A total of 12 mg ephedrine was administered.", + "Pulmonary arteriography was immediately performed.", + "The left pulmonary artery was patent.", + "The right pulmonary artery was totally defected.", + "A Swan–Ganz catheter was unable to pass the main branch of the right pulmonary artery.", + "Bronchoscopy was performed.", + "Complete compression of the left main bronchus was noted.", + "We finally diagnosed sudden hemodynamic collapse and hypoxia as simultaneous compression of both right pulmonary artery and left main bronchus.", + "Percutaneous cardiopulmonary support (PCPS) was conducted.", + "The operation was discontinued.", + "The patient was transferred to the intensive care unit.", + "After the patient regained consciousness from anesthesia, his hemodynamic collapse was gradually improved.", + "Weaning of PCPS was achieved without use of inotropes.", + "Bronchoscopy revealed that occlusion of the left main bronchus disappeared.", + "The patient was successfully extubated.", + "He recovered the next day without neurological deficit.", + "At the second surgery, PCPS was initiated with local anesthesia before general anesthesia and intubation.", + "We denuded the right femoral vein and artery.", + "Cannulas for PCPS were introduced.", + "General anesthesia was conducted carefully.", + "Bronchoscopy after intubation found out that the left main bronchus was almost occluded.", + "His oxygen saturation was not decreased.", + "PCPS was thought to be useful to prevent from hypoxia and hemodynamic collapse.", + "The aortic valve prosthesis that previously replaced was completely intact.", + "The aortic aneurysm occupied from just above the prosthesis to the distal aortic arch.", + "We successfully performed total arch replacement.", + "We performed reconstruction of bilateral coronary arteries.", + "We performed reconstruction of the brachiocephalic artery.", + "We performed reconstruction of the left common carotid artery.", + "We performed reconstruction of the left subclavian artery.", + "There were no adverse events during the second surgery." + ], + "summary": "We present the case of a 32-year-old man with a 10-cm aneurysm in the ascending aorta. A total aortic arch replacement was planned. After intravenous anesthesia, his aneurysm occluded the left main bronchus and right pulmonary artery simultaneously, and induced severe hypoxia. Percutaneous cardiopulmonary support was conducted and the patient recovered from cardiopulmonary collapse successfully. After the patient regained consciousness from anesthesia, the findings of organ compressions disappeared. At the second surgery, percutaneous cardiopulmonary support was initiated with local anesthesia before general anesthesia and intubation. The operation was performed successfully without any adverse events.", + "summary_subclaims": [ + "The patient was a 32-year-old man.", + "He had a 10-cm aneurysm in the ascending aorta.", + "A total aortic arch replacement was planned.", + "After intravenous anesthesia, his aneurysm occluded the left main bronchus and right pulmonary artery simultaneously.", + "The occlusion induced severe hypoxia.", + "Percutaneous cardiopulmonary support was conducted.", + "The patient recovered from cardiopulmonary collapse successfully.", + "After the patient regained consciousness from anesthesia, the findings of organ compressions disappeared.", + "At the second surgery, percutaneous cardiopulmonary support was initiated with local anesthesia before general anesthesia and intubation.", + "The operation was performed successfully without any adverse events." + ] + }, + { + "id": "multiclinsum_test_526_en.txt", + "fulltext": "A 39-year-old female presented with a 10-month history of the right-sided neck pain and bilateral hand numbness/weakness, accompanied by leg heaviness. Her neck pain was exacerbated by movement but was also present at rest. She described an accident while on an all-terrain vehicle 2 years ago but did not recall sustaining any specific cervical injury. She exhibited 4/5 strength involving both hands and the right triceps, decreased sensation throughout the hands, with diminished light touch, pain, and temperature in the hands. Reflexes remained intact. The outside computed tomography obtained 2 months previously demonstrated osseous hypertrophy of the C1 lamina, while the cervical magnetic resonance (MR) showed a pseudoarticulation between the lamina of C1 and C2 .\nThe patient underwent left-sided C1 hemilaminectomy and partial C2 laminectomy at which time the thickened pseudoarticulation at C1 was removed and was sent for pathology. Histologically, it proved to be “benign osteocartilaginous tissue with fibrosis.” The patient did well and regained full strength bilaterally on postoperative day 1. Two weeks later, initial neck pain and prior numbness resolved. Postoperative flexion and extension films showed no delayed instability. Six months later, with mild residual occipital pain, the MR image demonstrated complete resection of the lesion and no residual left-sided stenosis.", + "fulltext_subclaims": [ + "The patient is a 39-year-old female.", + "She had a 10-month history of right-sided neck pain.", + "She had bilateral hand numbness and weakness.", + "She had leg heaviness.", + "She described an accident while on an all-terrain vehicle 2 years ago.", + "She did not recall sustaining any specific cervical injury.", + "She exhibited 4/5 strength in both hands.", + "She exhibited 4/5 strength in the right triceps.", + "She had decreased sensation throughout the hands.", + "She had diminished light touch in the hands.", + "She had diminished pain sensation in the hands.", + "She had diminished temperature sensation in the hands.", + "Reflexes remained intact.", + "The outside computed tomography obtained 2 months previously demonstrated osseous hypertrophy of the C1 lamina.", + "The cervical magnetic resonance showed a pseudoarticulation between the lamina of C1 and C2.", + "The patient underwent left-sided C1 hemilaminectomy.", + "The patient underwent partial C2 laminectomy.", + "The thickened pseudoarticulation at C1 was removed.", + "The removed tissue was sent for pathology.", + "Histologically, it proved to be 'benign osteocartilaginous tissue with fibrosis.'", + "The patient regained full strength bilaterally on postoperative day 1.", + "Initial neck pain and prior numbness resolved 2 weeks later.", + "Postoperative flexion and extension films showed no delayed instability.", + "Six months later, the MR image demonstrated complete resection of the lesion.", + "Six months later, the MR image showed no residual left-sided stenosis." + ], + "summary": "A 39-year-old female presented with neck pain and upper extremity weakness. Magnetic resonance/computed tomography studies documented a left-sided unilateral pseudoarticulation between the lamina of C1 and C2 causing compression of the dorsal spinal cord. Following resection of the accessory C1/C2 joint utilizing a C1 hemilaminectomy and partial C2 laminectomy, the patient's neck pain and weakness resolved. Histologically, the tissue showed benign osteocartilaginous tissue with no synovial capsule.", + "summary_subclaims": [ + "The patient is a 39-year-old female.", + "The patient presented with neck pain.", + "The patient presented with upper extremity weakness.", + "Magnetic resonance/computed tomography studies documented a left-sided unilateral pseudoarticulation between the lamina of C1 and C2.", + "The pseudoarticulation caused compression of the dorsal spinal cord.", + "The patient underwent resection of the accessory C1/C2 joint.", + "The resection was performed utilizing a C1 hemilaminectomy.", + "The resection was performed utilizing a partial C2 laminectomy.", + "The patient's neck pain resolved following surgery.", + "The patient's upper extremity weakness resolved following surgery.", + "Histologically, the tissue showed benign osteocartilaginous tissue.", + "The tissue showed no synovial capsule." + ] + }, + { + "id": "multiclinsum_test_1129_en.txt", + "fulltext": "A 40-year-old woman and her husband had recently travelled from the United States to Bogota, Colombia for 7 days. They spent time outdoors in both urban and rural areas. She recollects having had mosquito bites and had three bite marks on her leg. She was asymptomatic during her stay.\nOn day 3 after returning to the USA, she developed itching of her scalp. On day 4, she felt fatigued and developed low-grade fever and back pain. On day 5, she presented to the outpatient infectious diseases clinic for evaluation after her scalp became erythematous and she started developing a pruritic, maculopapular rash on her face and trunk that rapidly spread over her entire body. Her wrist and ankle joints became very painful and swollen. She also developed a pressure-like sensation behind her eyes with conjunctival redness.\nShe had received yellow fever vaccine previously. She lived in an area of Florida with no local transmission of CHIKV or DENV. There had been no other recent travel. Her husband who travelled with her was asymptomatic and was not tested.", + "fulltext_subclaims": [ + "The patient is a 40-year-old woman.", + "She and her husband had recently travelled from the United States to Bogota, Colombia for 7 days.", + "They spent time outdoors in both urban and rural areas.", + "She recollects having had mosquito bites.", + "She had three bite marks on her leg.", + "She was asymptomatic during her stay.", + "On day 3 after returning to the USA, she developed itching of her scalp.", + "On day 4, she felt fatigued.", + "On day 4, she developed low-grade fever.", + "On day 4, she developed back pain.", + "On day 5, she presented to the outpatient infectious diseases clinic.", + "On day 5, her scalp became erythematous.", + "On day 5, she started developing a pruritic, maculopapular rash on her face and trunk.", + "The rash rapidly spread over her entire body.", + "Her wrist and ankle joints became very painful and swollen.", + "She developed a pressure-like sensation behind her eyes.", + "She had conjunctival redness.", + "She had received yellow fever vaccine previously.", + "She lived in an area of Florida with no local transmission of CHIKV or DENV.", + "There had been no other recent travel.", + "Her husband who travelled with her was asymptomatic.", + "Her husband was not tested." + ], + "summary": "On her return to the USA, a traveller to Colombia, South America developed an illness consistent with Zika, Chikungunya and/or Dengue. RT-PCR of her samples was positive only for ZIKV. However, arthralgias persisted for months, raising concerns about co-infection with CHIKV or Mayaro viruses. Cell cultures inoculated with her original clinical samples demonstrated two types of cytopathic effects, and both ZIKV and CHIKV were identified in the supernatants. On phylogenetic analyses, both viruses were found to be related to strains found in Colombia.", + "summary_subclaims": [ + "The patient is a traveller to Colombia, South America.", + "She developed an illness consistent with Zika, Chikungunya and/or Dengue.", + "RT-PCR of her samples was positive only for ZIKV.", + "Arthralgias persisted for months.", + "Cell cultures inoculated with her original clinical samples demonstrated two types of cytopathic effects.", + "Both ZIKV and CHIKV were identified in the supernatants.", + "On phylogenetic analyses, both viruses were found to be related to strains found in Colombia." + ] + }, + { + "id": "multiclinsum_test_1202_en.txt", + "fulltext": "A 63-year-old man was diagnosed with schizophrenia at age 49 and had been treated at the outpatient department of Songde Branch of Taipei City Hospital since the diagnosis. His symptoms included delusional jealousy, persecutory delusion, irritability, self-destructive behaviour and self-talk. Sulpiride 600 mg/day was prescribed but he quit the outpatient follow-up 2 months later. From age 50, he had an average daily consumption of four standard drinks of alcohol. Drinking worsened his impulse control and caused him to get into conflicts with his neighbours. He had been admitted to the acute psychiatric ward of Songde Branch of Taipei City Hospital three times since age 55. Brain computed tomography was performed that showed mild bilateral frontal lobe atrophy, but no other significant abnormal findings were identified. Benzodiazepine and thiamine were given whenever he was admitted for the prevention of Wernicke’s encephalopathy and alcohol withdrawal symptoms. Neither acute confusion state nor obvious amnesia was noted during admission.\nRisperidone 4 mg/day was used at first during admission for about 1 month with significant improvement in his psychotic symptoms. Unfortunately, the side effect dysphasia occurred and the patient developed aspiration pneumonia. Therefore, risperidone treatment was ceased and quetiapine was prescribed with gradual increase in dosage to about 550 mg/day. However, the treatment efficacy was not satisfactory in this patient.\nAt age 62, amisulpride at a dosage of 400 mg/day was prescribed instead in the outpatient department. After 6 months, obvious akathisia was noted, and he was transferred to Bali psychiatric centre for further treatment. The amisulpride dosage was tapered to 200 mg/day. His psychotic symptoms remained stable, but the side effects persisted, and amisulpride was further reduced to 50 mg/day gradually. His akathisia showed improvement, but he began to suffer from other forms of abnormal involuntary movements comprising dyskinesia mixed with dystonia and akathisia. The involuntary movements involved his trunk, head and neck, and four limbs. He kept twisting his body and head around or back and forth (Additional file : Video 1), which may be the dyskinesia symptoms mixed with the cervical dystonia. Further, the feeling of inner restlessness and a compelling need to be in constant motion meant that akathisia played a role in his abnormal involuntary movements. Meanwhile, the stepping movement could also be observed when he was made to sit (Additional file : Video 1). According to the patient and his family’s report, the abnormal involuntary movements, which were subsequent to the dosage reduction of amisulpride, never occurred previously.\nThe symptoms persisted for 2 weeks until amisulpride was increased to 100 mg/day. He still had slightly involuntary movement of his head and body but with much declined severity (Additional file : Video 2). Besides the adjustment of antipsychotic dosage, we used propranolol 10 mg twice a day for treatment of his akathisia and biperiden 0.5 mg twice a day for some dystonia-like symptoms. Further, lorazepam (0.5 mg twice a day) was prescribed for supplementary treatment of akathisia and dyskinesia for about 2 weeks. After discharge, the patient got relapsed about 1 year later with poor treatment adherence. The abnormal involuntary movements were still noted, although very mild, even though he did not take any psychotropic medications for about 3 months.", + "fulltext_subclaims": [ + "The patient was diagnosed with schizophrenia at age 49.", + "He had been treated at the outpatient department of Songde Branch of Taipei City Hospital since the diagnosis.", + "His symptoms included delusional jealousy.", + "His symptoms included persecutory delusion.", + "His symptoms included irritability.", + "His symptoms included self-destructive behaviour.", + "His symptoms included self-talk.", + "Sulpiride 600 mg/day was prescribed.", + "He quit the outpatient follow-up 2 months later.", + "From age 50, he had an average daily consumption of four standard drinks of alcohol.", + "Drinking worsened his impulse control.", + "Drinking caused him to get into conflicts with his neighbours.", + "He had been admitted to the acute psychiatric ward of Songde Branch of Taipei City Hospital three times since age 55.", + "Brain computed tomography showed mild bilateral frontal lobe atrophy.", + "No other significant abnormal findings were identified on brain computed tomography.", + "Benzodiazepine and thiamine were given whenever he was admitted.", + "Benzodiazepine and thiamine were given for the prevention of Wernicke’s encephalopathy.", + "Benzodiazepine and thiamine were given for the prevention of alcohol withdrawal symptoms.", + "Neither acute confusion state nor obvious amnesia was noted during admission.", + "Risperidone 4 mg/day was used at first during admission for about 1 month.", + "There was significant improvement in his psychotic symptoms with risperidone.", + "The side effect dysphasia occurred with risperidone.", + "The patient developed aspiration pneumonia with risperidone.", + "Risperidone treatment was ceased.", + "Quetiapine was prescribed with gradual increase in dosage to about 550 mg/day.", + "The treatment efficacy was not satisfactory in this patient.", + "At age 62, amisulpride at a dosage of 400 mg/day was prescribed instead in the outpatient department.", + "After 6 months, obvious akathisia was noted.", + "He was transferred to Bali psychiatric centre for further treatment.", + "The amisulpride dosage was tapered to 200 mg/day.", + "His psychotic symptoms remained stable.", + "The side effects persisted.", + "Amisulpride was further reduced to 50 mg/day gradually.", + "His akathisia showed improvement.", + "He began to suffer from other forms of abnormal involuntary movements comprising dyskinesia mixed with dystonia and akathisia.", + "The involuntary movements involved his trunk, head and neck, and four limbs.", + "He kept twisting his body and head around or back and forth.", + "The abnormal involuntary movements were subsequent to the dosage reduction of amisulpride.", + "The abnormal involuntary movements never occurred previously.", + "The symptoms persisted for 2 weeks until amisulpride was increased to 100 mg/day.", + "He still had slightly involuntary movement of his head and body but with much declined severity.", + "Propranolol 10 mg twice a day was used for treatment of his akathisia.", + "Biperiden 0.5 mg twice a day was used for some dystonia-like symptoms.", + "Lorazepam 0.5 mg twice a day was prescribed for supplementary treatment of akathisia and dyskinesia for about 2 weeks.", + "The patient got relapsed about 1 year later with poor treatment adherence.", + "The abnormal involuntary movements were still noted, although very mild, even though he did not take any psychotropic medications for about 3 months." + ], + "summary": "A 63-year-old man, who was diagnosed with schizophrenia at age 49, received amisulpride treatment since age 62. The dosage of amisulpride was reduced from 200 to 50 mg/day because of occurrence of akathisia during one admission. Severe withdrawal dyskinesia, mixed with dystonia and akathisia, was noted immediately after the dosage reduction. The abnormal involuntary movement showed improvement 2 weeks later when the dosage was increased to 100 mg/day.", + "summary_subclaims": [ + "The patient is a 63-year-old man.", + "The patient was diagnosed with schizophrenia at age 49.", + "The patient received amisulpride treatment since age 62.", + "The dosage of amisulpride was reduced from 200 to 50 mg/day.", + "The dosage reduction occurred because of the occurrence of akathisia during one admission.", + "Severe withdrawal dyskinesia, mixed with dystonia and akathisia, was noted immediately after the dosage reduction.", + "The abnormal involuntary movement showed improvement 2 weeks later.", + "The dosage was increased to 100 mg/day." + ] + }, + { + "id": "multiclinsum_test_1584_en.txt", + "fulltext": "The patient was a 13-year-old Japanese boy, the first of three siblings from non-consanguineous parents. He had no history of statin exposure and no family history of neuromuscular disease. He was a basketball player and presented with progressive difficulties in shooting, running, and subsequently walking during the previous one month.\nVital signs were normal (heart rate, 82 beats/min; respiratory rate, 15 breaths/min; blood pressure, 113/57 mmHg; body temperature, 36.5°C). Physical examination revealed grade 3/5 muscle weakness in the upper extremities and 4/5 in the lower extremities based on the Medical Research Council (MRC) scale (0–5) . The patient also presented with generalized erythematous skin rash . Other general physical examination findings were unremarkable.\nSerum levels of CK (19,306 U/L), aldolase (257 U/L), aspartate aminotransferase (274 U/L), and lactate dehydrogenase (1,471 U/L) were all elevated. Magnetic resonance imaging detected signal hyperintensity on T2-weighted imaging and short tau inversion recovery imaging for muscles in the proximal upper and lower extremities . Muscle biopsy showed necrosis and regeneration of muscle fibers . Immunohistochemistry demonstrated overexpression of major histocompatibility complex class 1 and membrane attack complex (C5b−9) on the sarcolemma and granular sarcoplasmic expression of p62 . As measured by quantitative enzyme-linked immunosorbent assay (Cosmic Corporation, Tokyo, Japan), anti-HMGCR antibody level was 2.9 IU/ml (reference value <1.0 IU/ml), while negative results were obtained for anti-signal recognition particle antibody and other myositis-associated antibodies, including anti-Jo-1, anti-Mi-2, anti-MDA-5, and anti-TIF-1 gamma antibodies. The patient was subsequently diagnosed with anti-HMGCR myopathy.\nBased on the consensus statement on the initial treatment for anti-HMGCR myopathy from the 224th European Neuromuscular Centre International Workshop , intravenous methylprednisolone (1 g/day for 3 days) followed by oral prednisolone (1 mg/kg/day), monthly IVIg (2 g/kg/dose, three times), and oral methotrexate (0.3 mg/kg/week) was started 3 months after the first evaluation. MRC scale scores for the upper and lower extremities normalized (grade 5/5) and serum CK (201 U/L), aldolase (8 U/L), aspartate aminotransferase (16 U/L), and lactate dehydrogenase (280 U/L) levels were all decreased by 3 months after treatment initiation. The patient resumed playing basketball at the same level as that before the onset of anti-HMGCR myopathy. The patient has continued to receive methotrexate monotherapy and as of the time of writing, has remained relapse-free for 2 years.\nWe searched PubMed using the terms “myositis[mh]” and “necrosis[mh]” or “anti-HMGCR[tiab]” up to July 31, 2022. This electronic search identified 710 records. Inclusion criteria were as follows: (1) studies including patients with anti-HMGCR myopathy <18 years old; and (2) anti-HMGCR myopathy diagnosed by both anti-HMGCR antibody and compatible myopathological features such as prominent necrosis and regeneration of muscle fibers with mild or absent inflammatory infiltrates. Duplicated publications, conference abstracts, and other studies that did not report the detailed clinical features of patients were excluded. We excluded 697 articles based on these eligibility criteria. A total of 13 articles were included in the final review, containing 33 pediatric cases with anti-HMGCR myopathy as confirmed by positive results for anti-HMGCR antibody and consistent myopathological findings with detailed information . Clinical response to treatment was evaluated based on the definition of complete remission as normalized motor function and serum CK level and partial remission as improved but not normalized motor function and serum CK level. For the 34 pediatric patients, including our own case, median age at onset was 9 years [interquartile rage (IQR), 5–11 years] and a maximum serum CK level >5,000 IU/L was observed in 32 patients (94%). Skin rash was noted in 15 patients (44%). Among the 15 patients with skin rash, 12 (80%) presented with erythematous rash, 1 with hyperpigmentation, 1 with linear morphea scleroderma, and 1 with rash of unknown detail. Skin rash was localized in 10 patients (67%; on the extremities in 6 [40%] on the face or neck in 4 [27%]), generalized in 2 (13%), and unknown in the other 3. A significant positive correlation was confirmed between age at onset and maximum serum CK level (Pearson correlation coefficient = 0.45, P = 0.0074). In one patient diagnosed in infancy, maximum serum CK level was only 918 IU/L . Patients were stratified by age at onset before and after school age (7–17 years vs. <7 years) and clinical characteristics were compared between groups . The cumulative incidence of skin rash and median maximum serum CK level was significantly higher in pediatric patients ≥7 years old at onset than in those <7 years old.", + "fulltext_subclaims": [ + "The patient was a 13-year-old Japanese boy.", + "He had no history of statin exposure.", + "He had no family history of neuromuscular disease.", + "He was a basketball player.", + "He presented with progressive difficulties in shooting, running, and walking during the previous one month.", + "Vital signs were normal.", + "Physical examination revealed grade 3/5 muscle weakness in the upper extremities.", + "Physical examination revealed grade 4/5 muscle weakness in the lower extremities.", + "The patient presented with generalized erythematous skin rash.", + "Serum levels of CK were elevated.", + "Serum levels of aldolase were elevated.", + "Serum levels of aspartate aminotransferase were elevated.", + "Serum levels of lactate dehydrogenase were elevated.", + "Magnetic resonance imaging detected signal hyperintensity on T2-weighted imaging for muscles in the proximal upper and lower extremities.", + "Muscle biopsy showed necrosis and regeneration of muscle fibers.", + "Immunohistochemistry demonstrated overexpression of major histocompatibility complex class 1 on the sarcolemma.", + "Immunohistochemistry demonstrated granular sarcoplasmic expression of p62.", + "Anti-HMGCR antibody level was 2.9 IU/ml.", + "The reference value for anti-HMGCR antibody is <1.0 IU/ml.", + "The patient was diagnosed with anti-HMGCR myopathy.", + "Intravenous methylprednisolone (1 g/day for 3 days) was started.", + "Oral prednisolone (1 mg/kg/day) was started.", + "Monthly IVIg (2 g/kg/dose, three times) was started.", + "Oral methotrexate (0.3 mg/kg/week) was started.", + "MRC scale scores for the upper and lower extremities normalized to grade 5/5.", + "Serum CK levels were decreased by 3 months after treatment initiation.", + "The patient resumed playing basketball at the same level as before the onset of anti-HMGCR myopathy.", + "The patient has remained relapse-free for 2 years.", + "We searched PubMed using the terms “myositis[mh]” and “necrosis[mh]” or “anti-HMGCR[tiab]” up to July 31, 2022.", + "This electronic search identified 710 records.", + "A total of 13 articles were included in the final review.", + "The 13 articles contained 33 pediatric cases with anti-HMGCR myopathy.", + "Clinical response to treatment was evaluated based on the definition of complete remission as normalized motor function and serum CK level.", + "Clinical response to treatment was evaluated based on the definition of partial remission as improved but not normalized motor function and serum CK level.", + "The median age at onset was 9 years.", + "Maximum serum CK level >5,000 IU/L was observed in 32 patients.", + "Skin rash was noted in 15 patients.", + "Among the 15 patients with skin rash, 12 presented with erythematous rash.", + "Skin rash was localized in 10 patients.", + "Skin rash was generalized in 2 patients.", + "A significant positive correlation was confirmed between age at onset and maximum serum CK level.", + "In one patient diagnosed in infancy, maximum serum CK level was only 918 IU/L.", + "Patients were stratified by age at onset before and after school age.", + "The cumulative incidence of skin rash and median maximum serum CK level was significantly higher in pediatric patients ≥7 years old at onset than in those <7 years old." + ], + "summary": "We report a pediatric case of anti-HMGCR myopathy accompanied by skin rash. Motor function and serum creatine kinase level normalized after combinational treatment including early intravenous immunoglobulin, methotrexate, and corticosteroid.", + "summary_subclaims": [ + "The patient was a pediatric case of anti-HMGCR myopathy.", + "The patient had a skin rash.", + "The treatment included early intravenous immunoglobulin.", + "The treatment included methotrexate.", + "The treatment included corticosteroid.", + "Motor function normalized after the combinational treatment.", + "Serum creatine kinase level normalized after the combinational treatment." + ] + }, + { + "id": "multiclinsum_test_1568_en.txt", + "fulltext": "A 70-year-old woman Gravid 12 was referred to the Tumor Clinic of Ghaem Hospital, Mashhad University of Medical Sciences in September 2013. Her symptoms were abdominal pain, loss of appetite, nausea, and vomiting from 20 days ago with a history of moderate hematemesis. No severe disease was observed in her medical records. She looked dehydrated and ill in terms of general appearance. Vital signs were blood pressure 70/50 Hgmm, pulse rate 100/minute, temperature 36.1°C and respiratory rate 14/minute. Laboratory studies detected leukocytes 20000 and PMN 87%. Liver and kidney function tests were normal. She was misdiagnosed with the left bundle block view in ECG and the AF rhythm in auscultation which caused her to undergo medical therapy in CCU. At first admission in hospital, abdominal examination revealed tenderness in the right and left lower quadrant of abdomen without rebound tenderness and guarding, and evidence of rigidity and abdominal distention.\nIn sonography evaluation, size of uterus was 133.5 × 80.5 cm with hypoechoic mass 101 × 109 cm in the left lateral of uterine body, which could be probably interpreted as uterine myoma, and some free fluid in peritoneal cavity was also reported. Paracentesis 5 mL suppurative fluid was aspirated under the guidance of sonography. Findings of CT-scan were a round cystic mass with focal calcification at its periphery located in the pelvic cavity with the diameter about 14 × 11.5 cm probably ovarian cyst adenoma ( and ).\nBased on the diagnosis of peritonitis (suppurative fluid aspirated), emergency laparotomy was performed and 700 mL of suppurative fluid in the abdominal cavity with normal appearance bowel and liver was found. The origin of pus draining was a 1 × 1 cm rupture in the anterior wall of uterus. However, there were multiple polypoid tumors in cervical canal yielded stenosis of cervical discharge. After peritoneal irrigation with 5 to 6 L of normal saline, total hysterectomy with bilateral salpango-oophorectomy was performed. Then, the patient received board-spectrum antibiotic. But in recovery image, the patient became oliguria with rise of creatinine level, and decrease of the blood pressure, despite normal hemoglobin level. Despite all medication and efforts performed, the general condition of the patient deteriorated and she expired ten hours after operation probably because of the septic or cardiogenic shock.", + "fulltext_subclaims": [ + "The patient was a 70-year-old woman Gravid 12.", + "She was referred to the Tumor Clinic of Ghaem Hospital, Mashhad University of Medical Sciences in September 2013.", + "Her symptoms were abdominal pain, loss of appetite, nausea, and vomiting from 20 days ago.", + "She had a history of moderate hematemesis.", + "No severe disease was observed in her medical records.", + "She looked dehydrated and ill in terms of general appearance.", + "Her blood pressure was 70/50 Hgmm.", + "Her pulse rate was 100/minute.", + "Her temperature was 36.1°C.", + "Her respiratory rate was 14/minute.", + "Laboratory studies detected leukocytes 20000.", + "PMN was 87%.", + "Liver and kidney function tests were normal.", + "She was misdiagnosed with the left bundle block view in ECG.", + "The AF rhythm was noted in auscultation.", + "This misdiagnosis caused her to undergo medical therapy in CCU.", + "At first admission in hospital, abdominal examination revealed tenderness in the right and left lower quadrant of abdomen.", + "There was no rebound tenderness.", + "There was no guarding.", + "There was no evidence of rigidity.", + "There was no abdominal distention.", + "In sonography evaluation, the size of the uterus was 133.5 × 80.5 cm.", + "A hypoechoic mass 101 × 109 cm was noted in the left lateral of uterine body.", + "The hypoechoic mass could be probably interpreted as uterine myoma.", + "Some free fluid in the peritoneal cavity was reported.", + "Paracentesis 5 mL suppurative fluid was aspirated under the guidance of sonography.", + "CT-scan findings were a round cystic mass with focal calcification at its periphery located in the pelvic cavity.", + "The mass had a diameter about 14 × 11.5 cm.", + "The mass was probably ovarian cyst adenoma.", + "Based on the diagnosis of peritonitis (suppurative fluid aspirated), emergency laparotomy was performed.", + "700 mL of suppurative fluid in the abdominal cavity was found.", + "The bowel and liver had normal appearance.", + "The origin of pus draining was a 1 × 1 cm rupture in the anterior wall of uterus.", + "Multiple polypoid tumors in cervical canal yielded stenosis of cervical discharge.", + "After peritoneal irrigation with 5 to 6 L of normal saline, total hysterectomy with bilateral salpango-oophorectomy was performed.", + "The patient received board-spectrum antibiotic.", + "In recovery image, the patient became oliguria.", + "There was a rise of creatinine level.", + "There was a decrease of the blood pressure.", + "The hemoglobin level was normal.", + "Despite all medication and efforts performed, the general condition of the patient deteriorated.", + "She expired ten hours after operation.", + "She probably expired because of the septic or cardiogenic shock." + ], + "summary": "This is a case report on spontaneously perforated associated with pyometra secondary to cervical malignancy. The patient underwent exploratory laparotomy with total hysterectomy and bilateral salpingo-oophorectomy.", + "summary_subclaims": [ + "This is a case report on spontaneously perforated associated with pyometra secondary to cervical malignancy.", + "The patient underwent exploratory laparotomy with total hysterectomy and bilateral salpingo-oophorectomy." + ] + }, + { + "id": "multiclinsum_test_2528_en.txt", + "fulltext": "A 45-year-old Caucasian man presented to our Urology department with a palpable left scrotal mass, known for two years, which had progressively enlarged during the last three months. He reported no history of epididymitis, torsion or trauma. On clinical examination the mass was painless, firm and mobile. His serum tumor markers, including alpha-fetoprotein, beta-human chorionic gonadotropin and lactate dehydrogenase, were normal.\nSonographic examination showed a sharply-demarcated hypoechoic, vascular left paratesticular mass, located close to the head of his epididymis. A large left hydrocele, with low level echoes was also found. MRI evaluation of the scrotum was done on a 1.5-T magnet unit, using a pelvic phased-array coil. The study included fast spin-echo axial, sagittal and coronal T2-weighted sequences and spin-echo axial T1-weighted sequences. Diffusion imaging was performed in the axial plane, using a single shot, multi-slice spin-echo planar diffusion pulse sequence. The maximum b-value was 900 s/mm2. A multilobular left paratesticular mass , in close proximity to the testicular tunicae of the superoanterior aspect of his left testis was detected. The dimensions of the tumor were 33 × 34 × 32 mm. T1-weighted images demonstrated a mass isointense to his testicular parenchyma . The mass was heterogeneous on T2-weighted and apparent diffusion coefficient (ADC) maps, with areas of high T2 signal and ADC value of 1.56 × 10-3mm2/s, and others of very low T2 signal and ADC value of 0.86 × 10-3 mm2/s . A large, left hydrocele, with a few septa and ADC value of 2.93 × 10-3mm2/s was also revealed. Both of his testicles, his epididymis and his spermatic cords were normal. The mean ADC value of his testicular parenchyma was 0.94 × 10-3 mm2/s and that of the epididymis 1.37 × 10-3mm2/s. His left testicular tunicae were intact. Based on MRI findings, the diagnosis of a benign fibromatous paratesticular tumor was suggested. Therefore, our patient underwent local excision of the mass. Histopathology reported an adenomatoid tumor of the tunica albuginea, with abundant fibrosis. Our patient is now well, without signs of disease on clinical and sonographic examination, one year after surgery.", + "fulltext_subclaims": [ + "The patient is a 45-year-old Caucasian man.", + "He presented with a palpable left scrotal mass.", + "The mass had been known for two years.", + "The mass had progressively enlarged during the last three months.", + "He reported no history of epididymitis.", + "He reported no history of torsion.", + "He reported no history of trauma.", + "On clinical examination, the mass was painless.", + "On clinical examination, the mass was firm.", + "On clinical examination, the mass was mobile.", + "His serum alpha-fetoprotein was normal.", + "His serum beta-human chorionic gonadotropin was normal.", + "His serum lactate dehydrogenase was normal.", + "Sonographic examination showed a sharply-demarcated hypoechoic, vascular left paratesticular mass.", + "The mass was located close to the head of his epididymis.", + "A large left hydrocele with low level echoes was found.", + "MRI evaluation of the scrotum was done on a 1.5-T magnet unit.", + "The study included fast spin-echo axial, sagittal and coronal T2-weighted sequences.", + "The study included spin-echo axial T1-weighted sequences.", + "Diffusion imaging was performed in the axial plane.", + "The maximum b-value was 900 s/mm2.", + "A multilobular left paratesticular mass was detected.", + "The tumor dimensions were 33 × 34 × 32 mm.", + "T1-weighted images demonstrated a mass isointense to his testicular parenchyma.", + "The mass was heterogeneous on T2-weighted and apparent diffusion coefficient (ADC) maps.", + "The mass had areas of high T2 signal and ADC value of 1.56 × 10-3 mm2/s.", + "The mass had areas of very low T2 signal and ADC value of 0.86 × 10-3 mm2/s.", + "A large, left hydrocele with a few septa was revealed.", + "The hydrocele had an ADC value of 2.93 × 10-3 mm2/s.", + "Both of his testicles were normal.", + "His epididymis was normal.", + "His spermatic cords were normal.", + "The mean ADC value of his testicular parenchyma was 0.94 × 10-3 mm2/s.", + "The mean ADC value of his epididymis was 1.37 × 10-3 mm2/s.", + "His left testicular tunicae were intact.", + "Based on MRI findings, the diagnosis of a benign fibromatous paratesticular tumor was suggested.", + "The patient underwent local excision of the mass.", + "Histopathology reported an adenomatoid tumor of the tunica albuginea.", + "The tumor had abundant fibrosis.", + "The patient is now well.", + "There were no signs of disease on clinical and sonographic examination one year after surgery." + ], + "summary": "A 45-year-old Caucasian man was referred to us with a palpable left scrotal mass. Magnetic resonance imaging of his scrotum revealed the presence of a multilobular left paratesticular mass, mainly detected with very low signal intensity on T2-weighted images and restricted diffusion on apparent diffusion coefficient maps. These findings were suggestive of a fibrous component, and were confirmed on histology following lesion excision.", + "summary_subclaims": [ + "The patient is a 45-year-old Caucasian man.", + "The patient was referred with a palpable left scrotal mass.", + "Magnetic resonance imaging of the scrotum was performed.", + "The imaging revealed a multilobular left paratesticular mass.", + "The mass was mainly detected with very low signal intensity on T2-weighted images.", + "The mass showed restricted diffusion on apparent diffusion coefficient maps.", + "These findings were suggestive of a fibrous component.", + "Histology following lesion excision confirmed the findings." + ] + }, + { + "id": "multiclinsum_test_2785_en.txt", + "fulltext": "An 8-year-old boy presented with pain in his left hip joint that had persisted for several months. His height was 112.5 cm (−2.93 standard deviation), and his weight was 21.5 kg, from which body mass index was calculated to 67.1 percentile for age and sex. His growth had started to slow at 4 years of age . He presented with hirsutism, dry skin, and bradycardia. Hip joint radiography revealed Trethowan’s sign bilaterally in the frontal view and a posterior tilting angle of 34° on the left side and 25° on the right side in the Lauenstein view . Magnetic resonance imaging (MRI) of the hip joint showed separation of the proximal metaphysis of the femur. Based on these findings, the patient was diagnosed with chronic bilateral SCFE (mild on the right side, moderate on the left side).\nBlood tests revealed hepatic dysfunction and hypercholesterolemia, with a very low free thyroxine level of 0.10 ng/dl and a very high thyroid-stimulating hormone (TSH) level of 1789 μIU/ml. The anti-thyroid peroxidase antibody level was >600 IU/ml, and the anti-thyroglobulin antibody level was 1720 IU/ml. At the age of 8 years 7 months, the bone age (assessed by the Tanner–Whitehouse 2 radius, ulna, short bones method) was 3 years 4 months. Ultrasonography showed marked atrophy of the thyroid, and color-flow Doppler sonography revealed decreased thyroid blood flow. Cardiac ultrasonography disclosed slight retention of pericardial fluid. MRI scans of the head showed that the anterior lobe of the pituitary gland was enlarged to a height of 17 mm. Although the pituitary gland displaced the optic chiasm superiorly, there were no visual acuity or field abnormalities. Hyperplasia of the anterior lobe of the pituitary gland caused by the overproduction of TSH was suspected. Therefore, atrophic thyroiditis was diagnosed.\nFor SCFE treatment, the patient was admitted and kept at rest, with the lower limbs in traction. Oral levothyroxine therapy was initiated with a low dose, followed by gradual dose increases. About 2 months later, the free thyroxine levels had increased to the normal range. In addition, the hirsutism, dry skin, and bradycardia had diminished, and his growth velocity had improved. MRI scans of the head showed reduction of the swollen pituitary gland. An arginine stimulation test (0.5 g/kg infused intravenously over 30 min) showed a normal growth hormone response (peak 7.26 ng/ml). Also, a human corticotropin-releasing hormone stimulation test (1.5 μg/kg infused intravenously) showed a normal adrenocorticotropic hormone response (peak 48.4 pg/ml) and cortisol response (peak 14.4 μg/dl). After 2 months of thyroxine treatment, the patient’s thyroid levels had stabilized, at which time surgery was performed for bilateral SCFE.\nThe CARE guidelines were followed in this case.", + "fulltext_subclaims": [ + "An 8-year-old boy presented with pain in his left hip joint that had persisted for several months.", + "His height was 112.5 cm (−2.93 standard deviation).", + "His weight was 21.5 kg.", + "His growth had started to slow at 4 years of age.", + "Hip joint radiography revealed Trethowan’s sign bilaterally in the frontal view.", + "Magnetic resonance imaging (MRI) of the hip joint showed separation of the proximal metaphysis of the femur.", + "The patient was diagnosed with chronic bilateral SCFE (mild on the right side, moderate on the left side).", + "Blood tests revealed a very low free thyroxine level of 0.10 ng/dl.", + "The anti-thyroid peroxidase antibody level was >600 IU/ml.", + "The anti-thyroglobulin antibody level was 1720 IU/ml.", + "Ultrasonography showed marked atrophy of the thyroid.", + "MRI scans of the head showed that the anterior lobe of the pituitary gland was enlarged to a height of 17 mm.", + "Hyperplasia of the anterior lobe of the pituitary gland caused by the overproduction of TSH was suspected.", + "Atrophic thyroiditis was diagnosed.", + "For SCFE treatment, the patient was admitted and kept at rest, with the lower limbs in traction.", + "Oral levothyroxine therapy was initiated with a low dose, followed by gradual dose increases.", + "About 2 months later, the free thyroxine levels had increased to the normal range.", + "MRI scans of the head showed reduction of the swollen pituitary gland.", + "An arginine stimulation test showed a normal growth hormone response (peak 7.26 ng/ml).", + "A human corticotropin-releasing hormone stimulation test showed a normal adrenocorticotropic hormone response (peak 48.4 pg/ml) and cortisol response (peak 14.4 μg/dl).", + "After 2 months of thyroxine treatment, the patient’s thyroid levels had stabilized, at which time surgery was performed for bilateral SCFE." + ], + "summary": "The patient was an 8-year-old boy suffering from bilateral SCFE with hypothyroidism. The patient's growth had started to slow at 4 years of age, and at 8 years he was of short stature. During his evaluation for SCFE management, primary hypothyroidism was diagnosed due to the presence of anti-thyroid peroxidase and anti-thyroglobulin antibodies. After the patient was treated for hypothyroidism, which improved his thyroid function, surgery was performed for bilateral SCFE.", + "summary_subclaims": [ + "The patient was an 8-year-old boy.", + "The patient had bilateral SCFE.", + "The patient had hypothyroidism.", + "The patient's growth had started to slow at 4 years of age.", + "At 8 years, the patient was of short stature.", + "During his evaluation for SCFE management, primary hypothyroidism was diagnosed.", + "The diagnosis of primary hypothyroidism was due to the presence of anti-thyroid peroxidase and anti-thyroglobulin antibodies.", + "After the patient was treated for hypothyroidism, which improved his thyroid function, surgery was performed for bilateral SCFE." + ] + }, + { + "id": "multiclinsum_test_1845_en.txt", + "fulltext": "A 55-year-old male with AS was presented with neck pain after falling off from a table while incarcerated. The non-contrast cervical computed tomography (CT) revealed a transverse three column fracture of the C6 cervical vertebra with minimal displacement; there was a mild kyphotic deformity and attendant evidence of multilevel auto-fusion of the spine consistent with the diagnosis of AS . The patient's body habitus precluded performing an MR (e.g., severe kyphosis).\nOriginally, the patient was intubated, and posterior fixation was attempted but aborted 2 days after admission (e.g., elevated peek pressures, inability to ventilate, and severe kyphosis). Somatosensory evoked potentials (SSEP) and motor evoked potentials (MEP) prior to and after positioning remained unchanged from baseline. The CT of the cervical spine following this aborted procedure revealed significant new malalignment and distraction of the fracture margin . Nevertheless, the progressive displacement mandated surgical fixation.\nFurther, a cervicothoracic fusion from C2 to T2 was performed in the right lateral decubitus position using the Mayfield head holder, a beanbag, and spinal neuronavigation. Throughout surgery, the SSEP and MEP signals were stable (e.g., before, after positioning, and postoperatively).\nReduction of the fracture was achieved predominately by positioning the patient in the Mayfield head rest. Segmental instrumentation with cervical lateral mass screws and thoracic pedicle screws was performed uneventfully. This was followed by posterolateral arthrodesis with allograft.\nThree weeks later, the patient remained neurologically intact and the wound healed. The postoperative CT confirmed adequate alignment, intact instrumentation, and a good reduction of the injury . A tracheostomy and percutaneous gastrostomy tube were placed owing to the patient's prolonged ventilator dependence and debility. He was transferred to an inpatient rehabilitation center by the 4th postoperative week.", + "fulltext_subclaims": [ + "The patient is a 55-year-old male with ankylosing spondylitis.", + "The patient had neck pain after falling off a table.", + "The fall occurred while the patient was incarcerated.", + "A non-contrast cervical CT showed a transverse three column fracture of the C6 cervical vertebra.", + "The CT showed minimal displacement of the C6 fracture.", + "The CT showed a mild kyphotic deformity.", + "The CT showed multilevel auto-fusion of the spine.", + "The CT findings were consistent with the diagnosis of ankylosing spondylitis.", + "The patient's body habitus precluded performing an MRI.", + "The patient was intubated.", + "Posterior fixation was attempted.", + "Posterior fixation was aborted 2 days after admission.", + "The reason for aborting posterior fixation included elevated peak pressures.", + "The reason for aborting posterior fixation included inability to ventilate.", + "The reason for aborting posterior fixation included severe kyphosis.", + "SSEP and MEP prior to and after positioning remained unchanged from baseline.", + "A postoperative CT after the aborted procedure showed significant new malalignment.", + "A postoperative CT after the aborted procedure showed distraction of the fracture margin.", + "Progressive displacement mandated surgical fixation.", + "A cervicothoracic fusion from C2 to T2 was performed.", + "The surgery was performed in the right lateral decubitus position.", + "The Mayfield head holder was used during surgery.", + "A beanbag was used during surgery.", + "Spinal neuronavigation was used during surgery.", + "SSEP and MEP signals were stable before positioning.", + "SSEP and MEP signals were stable after positioning.", + "SSEP and MEP signals were stable postoperatively.", + "Reduction of the fracture was achieved predominately by positioning the patient in the Mayfield head rest.", + "Segmental instrumentation with cervical lateral mass screws was performed.", + "Segmental instrumentation with thoracic pedicle screws was performed.", + "Posterolateral arthrodesis with allograft was performed.", + "Three weeks after surgery, the patient remained neurologically intact.", + "Three weeks after surgery, the wound had healed.", + "A postoperative CT confirmed adequate alignment.", + "A postoperative CT confirmed intact instrumentation.", + "A postoperative CT confirmed a good reduction of the injury.", + "A tracheostomy was placed.", + "A percutaneous gastrostomy tube was placed.", + "The tracheostomy and gastrostomy tube were placed due to prolonged ventilator dependence.", + "The tracheostomy and gastrostomy tube were placed due to debility.", + "The patient was transferred to an inpatient rehabilitation center by the 4th postoperative week." + ], + "summary": "A 55-year-old male with AS was presented with a three-column injury at the C6 level. The C6 vertebra was fractured, minimally displaced, and there was a focal kyphotic deformity. Attempted posterior fixation 2 days after presentation was aborted; the patient could not tolerate prone positioning, and there were further technical limitations to a posterior approach. Cervicothoracic fixation from C2 to T2 was then performed using the right lateral decubitus position employing the Mayfield head holder, a beanbag, and spinal neuronavigation.", + "summary_subclaims": [ + "The patient is a 55-year-old male with ankylosing spondylitis.", + "The patient had a three-column injury at the C6 level.", + "The C6 vertebra was fractured.", + "The C6 fracture was minimally displaced.", + "There was a focal kyphotic deformity.", + "Attempted posterior fixation 2 days after presentation was aborted.", + "The patient could not tolerate prone positioning.", + "There were further technical limitations to a posterior approach.", + "Cervicothoracic fixation from C2 to T2 was performed.", + "The fixation was performed using the right lateral decubitus position.", + "The Mayfield head holder was used.", + "A beanbag was used.", + "Spinal neuronavigation was used." + ] + }, + { + "id": "multiclinsum_test_3217_en.txt", + "fulltext": "A 49-year-old man with a history of acromegaly was admitted to our hospital with the concern of recurrent shortness of breath and dyspnea on exertion during the previous 2 years, and he had experienced an episode of presyncope 2 weeks prior without any further evaluation. He was a chef in a local restaurant for almost 30 years. He had no family history of any diseases and no past history of hypertension, diabetes mellitus, sleep apnea, or sudden cardiac death. He did not smoke or consume alcohol. The patient provided a history of stereotactic radiosurgeries twice in a decade or so and adherence to treatment with a somatostatin analog (octreotide given 40 mg once per month through intramuscular injection) at the time of diagnosis 20 years before. The patient was overweight and moderately nourished. He was 1.85 m (73 inches) tall, weighed 134 kg, and had a body mass index of 39 kg/m2. His blood pressure was 110/60 mmHg, and his heart rate was 92 beats/min with sinus rhythm. He had distinct skeletal features that included prominent superciliary arches and nose bridge, enlargement of the tongue and lip, and large hands and feet. Cardiac auscultation revealed irregular premature beats and pathological third heart sound, and a systolic murmur was discovered over the apex and aortic area. Bilateral extensive borders of cardiac dullness were noted. His physiological reflexes were present without any pathology. An electrocardiogram demonstrated sinus rhythm with wide (160 ms) QRS duration of left bundle branch block (LBBB). The patient’s condition was classified as New York Heart Association (NYHA) stage III–IV.\n\nOn admission, magnetic resonance imaging showed pituitary macroadenoma. Given the symptoms described, we arranged blood testing of myocardial injury markers showing an elevated brain natriuretic peptide level of 740 pg/ml indicating cardiac failure (Table 1). Hormone laboratory tests performed subsequently demonstrated excessive secretion of GH and IGF-1, twofold greater than the reference normal upper limit, which was consistent with pituitary macroadenoma (Table 2). Other routine analyses of liver and renal function were roughly normal.\n\nA Holter monitor was ordered for underlying arrhythmias to explain the patient’s dyspnea, chest discomfort, and presyncope. It demonstrated sinus rhythm with an average heart rate of 68 beats/min, frequent ventricular premature beats, and nonsustained ventricular tachycardia (up to 2200 ms).\n\nA chest x-ray showed a cardiothoracic ratio (CTR) of 78%. Echocardiography showed diffuse impairment of left ventricular (LV) systolic motion, reaching an LVEF of 16%. We noted hypertrophy of the ventricular septum at 18 mm, ventricular dilation, with LV diameter of 72 mm. The right ventricle and atrium and the left atrium were also dilated with moderate mitral regurgitation and mild tricuspid regurgitation. There was no associated systolic anterior motion (SAM) of the mitral valve. Dyssynchrony of the biventricular systolic motion was apparent.\n\nGiven an exertional component to the symptoms together with echo presentations in order to better exclude ischemic cardiomyopathy, coronary angiography was performed, which showed normal coronary arteries without stenosis, and left ventriculography applied simultaneously revealed an EF of 20% with diffuse LV hypokinesis.\n\nGiven the patient’s previous medical history of acromegaly, the absence of obstructive coronary artery imaging findings or segmental dyskinesia, family history of hypertrophic cardiomyopathy (HCM), symmetric hypertrophy, as well as absence of SAM of the mitral valve, acromegaly-induced cardiomyopathy was confirmed, which was absolutely opposed to coronary heart disease (CHD) and HCM.\n\nThese results indicated that it was probably not a case of hereditary cardiomyopathy; therefore, we diagnosed the patient as having secondary dilated cardiomyopathy due to acromegaly, even taking it a step further progressing to congestive heart failure secondary to acromegaly-induced dilated cardiomyopathy.\n\nChronic excess of GH and IGF-I secretion affects cardiac morphology and performance [5], so etiological treatment for acromegaly-induced cardiomyopathy is crucial to suppressing GH secretion or blocking GH action for the sake of reversing acromegaly-induced cardiomyopathy. The mainstay of treatment acknowledged globally is surgical resection of the pituitary adenoma [6], which was unfortunately considered high-risk given our patient’s cardiac condition (NYHA stage III–IV). Although stereotactic radiosurgery combined with somatostatin analogs and GH antagonists administrated previously were effective in suppressing hormones, they could not help his cardiac function. Therefore, we carefully administered diuretics, vasodilators, angiotensin-converting enzyme inhibitor (ACEI), β-blockers, and spironolactone for management of heart failure following the current guidelines [7]; in the meantime, octreotide (200 μg/day) was administered for the control of GH excess. After good compliance of pharmacotherapy and a regular medical examination regimen for nearly half a year, the serum GH and IGF-1 concentrations decreased from 32.50 ng/ml to 1.98 ng/ml and 627.00 ng/ml to 229.10 ng/ml, respectively, but the patient was hospitalized again because of uncontrollable cardiac failure. Accompanied by the normalization of GH and IGF-1 levels, the patient’s cardiac function did not seem to take a favorable turn upon readmission. Though echocardiography showed a recovered EF value from 16% to 28%, a significant ventricular mechanical dyssynchrony was detected as formerly. Electrophysiological study was performed using a nonaggressive stimulation protocol, which revealed a nonsustained ventricular monomorphic tachycardia. In the presence of overt ventricular dyssynchrony, complete LBBB, LVEF< 35%, inducible ventricular tachycardia, and symptomatic heart failure despite guideline-directed medical therapy, surgical indication was rarely assessed by neurosurgeons, and stereotactic radiosurgery together with pharmacotherapy produced infinitesimal effects. Therefore, we boldly recommended cardiac resynchronization therapy with defibrillator (CRT-D) implantation based on device implantation official guidelines. The patient underwent CRT insertion finally and was discharged to home 5 days later, pharmacotherapy continued as usual.\n\nTelephone follow-up was arranged, and the patient claimed symptom improvement following the device insertion 1 month later and was basically back to normal life. We required that he return for follow-up at 1 month, 3 months, and 6 months after the interventional therapy. The patient has been followed in our outpatient clinic for nearly half a year now. During his last visit, echocardiography identified improved LVEF of 54%, and a chest x-ray showed reduced CTR of 60%. The patient was in NYHA functional class II.", + "fulltext_subclaims": [ + "The patient was a 49-year-old man with a history of acromegaly.", + "He was admitted with recurrent shortness of breath and dyspnea on exertion during the previous 2 years.", + "He had experienced an episode of presyncope 2 weeks prior.", + "He had no past history of hypertension, diabetes mellitus, sleep apnea, or sudden cardiac death.", + "He did not smoke or consume alcohol.", + "He had a history of stereotactic radiosurgeries twice in a decade or so.", + "He was adherent to treatment with octreotide 40 mg once per month through intramuscular injection.", + "He was 1.85 m tall, weighed 134 kg, and had a body mass index of 39 kg/m2.", + "His blood pressure was 110/60 mmHg.", + "His heart rate was 92 beats/min with sinus rhythm.", + "He had prominent superciliary arches and nose bridge.", + "He had enlargement of the tongue and lip.", + "He had large hands and feet.", + "Cardiac auscultation revealed irregular premature beats.", + "An electrocardiogram demonstrated sinus rhythm with wide (160 ms) QRS duration of left bundle branch block.", + "The patient’s condition was classified as New York Heart Association stage III–IV.", + "Magnetic resonance imaging showed pituitary macroadenoma.", + "Blood testing showed an elevated brain natriuretic peptide level of 740 pg/ml.", + "Hormone laboratory tests demonstrated excessive secretion of GH and IGF-1, twofold greater than the reference normal upper limit.", + "A Holter monitor showed frequent ventricular premature beats.", + "A chest x-ray showed a cardiothoracic ratio of 78%.", + "Echocardiography showed diffuse impairment of left ventricular systolic motion, reaching an LVEF of 16%.", + "The right ventricle and atrium and the left atrium were dilated.", + "There was moderate mitral regurgitation.", + "There was no associated systolic anterior motion of the mitral valve.", + "Coronary angiography showed normal coronary arteries without stenosis.", + "Left ventriculography revealed an EF of 20% with diffuse LV hypokinesis.", + "Acromegaly-induced cardiomyopathy was confirmed.", + "The patient was diagnosed with secondary dilated cardiomyopathy due to acromegaly.", + "The patient was diagnosed with congestive heart failure secondary to acromegaly-induced dilated cardiomyopathy.", + "The mainstay of treatment acknowledged globally is surgical resection of the pituitary adenoma.", + "Surgical resection was considered high-risk given the patient’s cardiac condition.", + "The patient was administered diuretics, vasodilators, an ACEI, β-blockers, and spironolactone.", + "Octreotide (200 μg/day) was administered for the control of GH excess.", + "After half a year, the serum GH concentration decreased from 32.50 ng/ml to 1.98 ng/ml.", + "The patient was hospitalized again because of uncontrollable cardiac failure.", + "Echocardiography showed a recovered EF value from 16% to 28%.", + "A significant ventricular mechanical dyssynchrony was detected.", + "Electrophysiological study revealed a nonsustained ventricular monomorphic tachycardia.", + "We recommended cardiac resynchronization therapy with defibrillator implantation.", + "The patient underwent CRT insertion.", + "The patient was discharged to home 5 days after CRT insertion.", + "The patient claimed symptom improvement following device insertion 1 month later.", + "Echocardiography at the last visit identified improved LVEF of 54%.", + "A chest x-ray showed reduced CTR of 60%.", + "The patient was in NYHA functional class II." + ], + "summary": "We describe a case of a 49-year-old man with a history of acromegaly who presented to our hospital with a diagnosis of decompensated systolic heart failure. Serial electrocardiograms showed wide (160–200 ms) QRS duration with left bundle branch block. Echocardiography showed severe left ventricular dysfunction that simultaneously achieved a left ventricular ejection fraction of 16%. Surgical indication was rarely assessed by neurosurgeons. Given that the stereotactic radiosurgery together with pharmacotherapy produced infinitesimal effects, cardiac resynchronization therapy was performed. Owing to biventricular synchronization and holding back reverse remodeling, the patient’s symptoms were successfully alleviated, and he was discharged from the hospital.", + "summary_subclaims": [ + "The patient is a 49-year-old man.", + "The patient has a history of acromegaly.", + "The patient presented with decompensated systolic heart failure.", + "Serial electrocardiograms showed wide (160–200 ms) QRS duration.", + "Echocardiography showed severe left ventricular dysfunction.", + "The left ventricular ejection fraction was 16%.", + "Surgical indication was rarely assessed by neurosurgeons.", + "Stereotactic radiosurgery together with pharmacotherapy produced infinitesimal effects.", + "Cardiac resynchronization therapy was performed.", + "The patient’s symptoms were successfully alleviated.", + "The patient was discharged from the hospital." + ] + }, + { + "id": "multiclinsum_test_2845_en.txt", + "fulltext": "Our case is a 4 years and 8-month-old Syrian Arabic girl with a birth weight of 4 kg, who is the sixth of seven siblings born to healthy consanguineous parents. She followed normal psychomotor development and experienced no remarkable illness until the age of 4 years and 2 months when her parents noticed a rapid weight gain (about 1 kg every 10 to 15 days) due to excessive eating (she required six to seven big meals/day). Later, they observed her to have alterations in body secretion (decreased tears when crying, decreased nasal discharge, unfavorable body odor, and decreased sweating) in addition to blue cold extremities, diarrhea alternated with constipation, polyuria, and polydipsia. Two months after the onset of obesity she had urinary incontinence during night sleep. Then, significant behavioral changes developed including: mood alteration, anxiety episodes, rage attacks, nervousness, and aggressive behavior, in addition to recurrent fatigue, social withdrawal, prolonged periods of sleep (12 hours continuously), and difficulty staying awake during the day. These complaints grew to be a serious concern to the family so she was admitted to Damascus Children Hospital, endocrinal department, at the age of 4.5 years, for further investigations.\nFor three generations, the family history was negative for similar presentations, obesity, or psychiatric disorders. It was noteworthy that an older sister of our patient had died at the age of 12 years with a diagnosis of acute myeloid leukemia (AML). Her sister’s malignancy was not accompanied by any of the signs or symptoms our patient had.\nOn physical examination, general obesity was noticed without striae or altered skin pigmentation. No dysmorphic features were observed, neither were there any minor or major congenital malformations. Her weight was 25 kg (above 97% percentile) while her length and head circumference measured 110 cm (at 90% percentile) and 52 cm respectively. Her body mass index (BMI) was equal to 20.1 .\nAn ophthalmic examination revealed left exotropia with normal fundus and normal papillary response. The performed laboratory analyses did not indicate any significant abnormality. Her complete blood count (CBC), blood glucose, sodium (Na), chlorine (Cl), potassium (K), calcium (Ca), alanine aminotransferase (ALT), aspartate aminotransferase (AST), triglycerides (TG), cholesterol, urine density, creatinine, and urea were all within normal limits. Her thyroid-stimulating hormone (TSH), free thyroxine (T4), morning cortisol, adrenocorticotropic hormone (ACTH), prolactin, growth hormone (GH), insulin-like growth factor-1 (IGF1), follicle-stimulating hormone (FSH), and luteinizing hormone (LH) were also within normal limits.\nHer abdominal and pelvic ultrasound was normal. Her bone age was slightly advanced and it fitted 5 to 5.5 years old. Brain magnetic resonance imaging (MRI) was normal; it showed no cortical atrophy. A homogenous mild enlargement of her pituitary gland was observed on both T1-weighted and T2-weighted images with normal hyperintense posterior lobe on T1-weighted images .\nSince the endocrine function tests were normal, her symptoms had been explained on the basis of psychotropic origin, and she was discharged with antipsychotic medication (risperidone 1 mg orally per day) and the recommendation to follow up at the out-patient psychiatric clinic after 3 months of prescribed treatment. After 3 months of discharge, when she was 4 years and 8 months old, she developed dyspnea that worsened with exertion and during sleep, continuous snoring, and recurrent chest pain. The respiratory symptoms lasted for 5 days after which she had two episodes of cyanosis and obstructive apnea which lasted for 10 minutes with improvement via oxygen mask. As a result of progressive respiratory distress (respiratory rate 35/min, expiratory grunting, flaring of nostrils, wheezing with prolonged expiration, and remarkably loud snoring) she was readmitted to Damascus Children Hospital, intensive care unit (ICU). Investigations showed hypoxemia, hypercapnia, and respiratory acidosis accompanied by radiological evidence of a big round opacity in her right lung .\nShe was intubated 24 hours after admission and attached to a mechanical ventilator because of severe respiratory distress with altered consciousness: blood gases were pH 7.27, partial pressure of carbon dioxide (PaCO2) 79 mmHg, partial pressure of oxygen (PaO2) 38 mmHg, and oxygen saturation 79%. Her laboratory results were within normal limits except for elevated values of Na (up to 162) and C-reactive protein (77 mg/L). During this admission, her weight was recorded as 40 kg (>97th percentile).\nA chest computed tomography (CT) scan demonstrated a 6 cm round mass filling most of her right lung and pushing her heart and mediastinum to the left with infiltration and consolidation of the right lower lobe of her right lung .\nSubsequently, when her health stabilized, a complete resection was performed of a 10×10 cm solid round mass from the posterior wall of her chest. It was a mature ganglioneuroma .\nHer unexplained rapid gain of weight and the presence of chest ganglioneuroma brought attention to ROHAAD syndrome as a diagnosis of her situation and helped to exclude other illnesses that could be considered in the differential diagnosis. Familial obesity and Prader–Willi syndrome were both excluded since her family history did not support the first, and with the absence of mental retardation and congenital abnormalities there was no indication to investigate the latter.\nA good improvement in consciousness was achieved by stopping sedative drugs, so she was able to speak, move her limbs, and interact with others. Nevertheless, she required prolonged ventilation because of respiratory instability and she had myoclonic seizures. Three attempts at extubation failed without a clear reason. A brain MRI was ordered which revealed a generalized cortical atrophy of her brain with the same mild pituitary gland enlargement observed in a previous MRI .\nA month after her admission to the ICU, a tracheostomy was performed because of lack of spontaneous breathing. One week later, she had cardiorespiratory arrest and died. A timeline of her signs and symptoms is shown in Fig. .", + "fulltext_subclaims": [ + "The patient is a 4 years and 8-month-old Syrian Arabic girl.", + "She is the sixth of seven siblings.", + "She was born to healthy consanguineous parents.", + "She had a birth weight of 4 kg.", + "She followed normal psychomotor development.", + "She had no remarkable illness until the age of 4 years and 2 months.", + "Her parents noticed rapid weight gain starting at 4 years and 2 months.", + "She gained about 1 kg every 10 to 15 days.", + "She required six to seven big meals per day.", + "She had decreased tears when crying.", + "She had decreased nasal discharge.", + "She had unfavorable body odor.", + "She had decreased sweating.", + "She had blue cold extremities.", + "She had diarrhea alternated with constipation.", + "She had polyuria.", + "She had polydipsia.", + "Two months after the onset of obesity, she had urinary incontinence during night sleep.", + "She had mood alteration.", + "She had anxiety episodes.", + "She had rage attacks.", + "She had nervousness.", + "She had aggressive behavior.", + "She had recurrent fatigue.", + "She had social withdrawal.", + "She had prolonged periods of sleep (12 hours continuously).", + "She had difficulty staying awake during the day.", + "She was admitted to Damascus Children Hospital at the age of 4.5 years.", + "The family history was negative for similar presentations.", + "An older sister of the patient had died at the age of 12 years with a diagnosis of acute myeloid leukemia.", + "Her sister’s malignancy was not accompanied by any of the signs or symptoms the patient had.", + "On physical examination, general obesity was noticed.", + "No dysmorphic features were observed.", + "Her weight was 25 kg.", + "Her body mass index (BMI) was equal to 20.1.", + "Her bone age was slightly advanced and fitted 5 to 5.5 years old.", + "Brain MRI showed no cortical atrophy.", + "A homogenous mild enlargement of the pituitary gland was observed.", + "Her endocrine function tests were normal.", + "She was discharged with risperidone 1 mg orally per day.", + "She was recommended to follow up at the out-patient psychiatric clinic after 3 months.", + "After 3 months, she developed dyspnea that worsened with exertion and during sleep.", + "She had continuous snoring.", + "She had recurrent chest pain.", + "She had two episodes of cyanosis and obstructive apnea.", + "She was readmitted to the ICU.", + "She was intubated 24 hours after admission.", + "She was attached to a mechanical ventilator.", + "Her blood gases were pH 7.27, PaCO2 79 mmHg, PaO2 38 mmHg, and oxygen saturation 79%.", + "A chest CT scan demonstrated a 6 cm round mass filling most of her right lung.", + "A complete resection was performed of a 10×10 cm solid round mass.", + "The mass was a mature ganglioneuroma.", + "ROHAAD syndrome was considered as a diagnosis.", + "Familial obesity was excluded.", + "Prader–Willi syndrome was excluded.", + "A brain MRI revealed generalized cortical atrophy.", + "A tracheostomy was performed.", + "She had cardiorespiratory arrest.", + "She died one week after the tracheostomy." + ], + "summary": "We present a documented case of a 4 years and 8-month-old Syrian Arabic girl with a distinctive course of signs and symptoms of rapid-onset obesity with hypoventilation, hypothalamic dysfunction, and autonomic dysregulation syndrome accompanied by mature ganglioneuroma in her chest, a homogenous mild enlargement of her pituitary gland, generalized cortical brain atrophy, and seizures. Three months after her first marked symptoms were noted she had a sudden progression of severe respiratory distress that ended with her death.", + "summary_subclaims": [ + "The patient is a 4 years and 8-month-old Syrian Arabic girl.", + "The patient had signs and symptoms of rapid-onset obesity with hypoventilation.", + "The patient had hypothalamic dysfunction.", + "The patient had autonomic dysregulation syndrome.", + "The patient had a mature ganglioneuroma in her chest.", + "The patient had homogenous mild enlargement of her pituitary gland.", + "The patient had generalized cortical brain atrophy.", + "The patient had seizures.", + "Three months after her first marked symptoms were noted, she had a sudden progression of severe respiratory distress.", + "The patient's severe respiratory distress ended with her death." + ] + }, + { + "id": "multiclinsum_test_1209_en.txt", + "fulltext": "An unrelated natural couple brought an 11-month-old female with delayed development to the outpatient department for genetic counselling . There were no obvious abnormalities detected during the foetal period for this patient. After birth, the baby was found to have jaundice (lasting for 1 month), difficulties falling asleep and a small head circumference. At the age of 7 months, physical examination showed muscular hypertonia, hands often clenched, and global growth regression. The electroencephalogram showed bounded linearity. Cranial MRI showed that the volume of the bilateral cerebellar hemispheres was significantly decreased, especially in the lower part of cerebellar hemisphere, the cerebellar sulcus was widened and deepened, and the occipital cistern was widened (suspected cerebellar hemisphere dysplasia). Additionally, the signal of the bilateral globus pallidus changed slightly, the sulci of the bilateral cerebral hemispheres was slightly widened and deepened, the bilateral frontotemporal extracerebral space was slightly widened, and the bilateral lateral ventricles were slightly widened. At 11 months of age, the head circumference was 40 cm (< − 3 SD) (reference value: 41.9–47.3 cm) . The clinical diagnosis was primary microcephaly. There was no genetic history in the family, and the parents were not close relatives . We initially diagnosed the patient with intellectual developmental and microcephaly with pontine and cerebellar hypoplasia (MICPCH) based on the specific clinical characteristics. There were no phenotypic abnormalities observed in the parents of the patient.\nWe extracted DNA from the patient’s peripheral blood sample and performed WES. The results showed that the CASK gene had a heterozygous missense variant, specifically CASK: NM_003688.3: exon 7: c.638T>G: p.L213R. .\nAccording to the bioinformatics analysis, this variant was not previous reported and was not found in most databases, including the ExAC browser, 1000 Genomes Project, and In-house Chinese-Control. The latest gnomAD database indicates that the frequency of this variant is 0.000005520 . In addition, this variant site is highly conserved in many species according to mutation taster . PhastCons and PhyloP were used to evaluate the scores of amino acid sequence conservation. The scores indicated that this variant site is highly conserved . Moreover, this mutation was predicted to be deleterious by the following bioinformatic tools: SIFT , PolyPhen-2 , and M-CAP . The above results indicate that this variant site is pathogenic and well conserved.\nTo further confirm the negative effect of this variant on CASK expression, wild-type and mutant plasmids were constructed and transfected into HEK-293T cells. We determined the mRNA and protein expression of both the wild type and the mutant and found that there was no significant difference in mRNA expression between the wild type and the mutant. However, compared with the wild type, the protein expression of the mutant was downregulated.\nFinally, we predicted the structural pattern of the protein after the amino acid arginine (R) was substituted for leucine (L) by PSIPRED [–]. Importantly, the mutant protein showed decreased protein stability, which is represented by the increased Gibbs free energy (ΔΔGpred = 1.857). The results of the protein structure prediction showed that the nuclear charge of the protein increased (ΔCharge = 1) and the stability of the protein decreased (ΔΔGpred = 1.857) after the variant. Moreover, a random coil in the secondary structure is changed to a β-sheet, which also affects its spatial structure . Therefore, the decreased protein stability and the changed protein structure might contribute to the downregulation of CASK protein expression, further causing the loss of protein function.", + "fulltext_subclaims": [ + "An unrelated natural couple brought an 11-month-old female with delayed development to the outpatient department for genetic counselling.", + "There were no obvious abnormalities detected during the foetal period for this patient.", + "After birth, the baby was found to have jaundice lasting for 1 month.", + "After birth, the baby was found to have difficulties falling asleep.", + "After birth, the baby was found to have a small head circumference.", + "At the age of 7 months, physical examination showed muscular hypertonia.", + "At the age of 7 months, physical examination showed hands often clenched.", + "At the age of 7 months, physical examination showed global growth regression.", + "The electroencephalogram showed bounded linearity.", + "Cranial MRI showed that the volume of the bilateral cerebellar hemispheres was significantly decreased.", + "Cranial MRI showed that the cerebellar sulcus was widened and deepened.", + "Cranial MRI showed that the occipital cistern was widened.", + "Cranial MRI showed suspected cerebellar hemisphere dysplasia.", + "The signal of the bilateral globus pallidus changed slightly.", + "The sulci of the bilateral cerebral hemispheres was slightly widened and deepened.", + "The bilateral frontotemporal extracerebral space was slightly widened.", + "The bilateral lateral ventricles were slightly widened.", + "At 11 months of age, the head circumference was 40 cm (< − 3 SD).", + "The clinical diagnosis was primary microcephaly.", + "There was no genetic history in the family.", + "The parents were not close relatives.", + "We initially diagnosed the patient with intellectual developmental and microcephaly with pontine and cerebellar hypoplasia (MICPCH) based on the specific clinical characteristics.", + "There were no phenotypic abnormalities observed in the parents of the patient.", + "We extracted DNA from the patient’s peripheral blood sample and performed WES.", + "The results showed that the CASK gene had a heterozygous missense variant, specifically CASK: NM_003688.3: exon 7: c.638T>G: p.L213R.", + "This variant was not previously reported and was not found in most databases, including the ExAC browser, 1000 Genomes Project, and In-house Chinese-Control.", + "The latest gnomAD database indicates that the frequency of this variant is 0.000005520.", + "This variant site is highly conserved in many species according to mutation taster.", + "PhastCons and PhyloP were used to evaluate the scores of amino acid sequence conservation.", + "The scores indicated that this variant site is highly conserved.", + "This mutation was predicted to be deleterious by the following bioinformatic tools: SIFT, PolyPhen-2, and M-CAP.", + "The above results indicate that this variant site is pathogenic and well conserved.", + "Wild-type and mutant plasmids were constructed and transfected into HEK-293T cells.", + "There was no significant difference in mRNA expression between the wild type and the mutant.", + "Compared with the wild type, the protein expression of the mutant was downregulated.", + "The mutant protein showed decreased protein stability, which is represented by the increased Gibbs free energy (ΔΔGpred = 1.857).", + "The results of the protein structure prediction showed that the nuclear charge of the protein increased (ΔCharge = 1) and the stability of the protein decreased (ΔΔGpred = 1.857) after the variant.", + "A random coil in the secondary structure is changed to a β-sheet, which also affects its spatial structure.", + "The decreased protein stability and the changed protein structure might contribute to the downregulation of CASK protein expression, further causing the loss of protein function." + ], + "summary": "An 11-month-old female diagnosed with MICPCH exhibited general developmental delays, microcephaly, and cerebellar hypoplasia. Whole-exome sequencing (WES) was used to find a novel heterozygous missense variant (NM_003688.3: c.638T>G) of CASK in this patient. Strikingly, this variant reduced the expression of CASK at the protein level but not at the mRNA level. By using protein structure prediction analysis, this study found that the amino acid change caused by the variant resulted in further changes in the stability of the protein structure, and these changes caused the downregulation of protein expression and loss of protein function.", + "summary_subclaims": [ + "The patient is an 11-month-old female.", + "The patient was diagnosed with MICPCH.", + "The patient exhibited general developmental delays.", + "The patient had microcephaly.", + "The patient had cerebellar hypoplasia.", + "Whole-exome sequencing was used to find a novel heterozygous missense variant of CASK in this patient.", + "The variant is NM_003688.3: c.638T>G.", + "The variant reduced the expression of CASK at the protein level.", + "The variant did not reduce the expression of CASK at the mRNA level.", + "Protein structure prediction analysis was used in this study.", + "The amino acid change caused by the variant resulted in further changes in the stability of the protein structure.", + "These changes caused the downregulation of protein expression.", + "These changes caused the loss of protein function." + ] + }, + { + "id": "multiclinsum_test_2344_en.txt", + "fulltext": "A 71-year-old female patient with the right knee tri compartmental osteoarthritis underwent a right TKA using a posterior stabilized (PS) fixed bearing cobalt chrome implant (PFC Sigma DePuy, Synthes). The surgery was performed through a medial para patellar approach. A combination of measured and gap resection method was used for ligament and flexion/extension balancing. The implant component used was size two femur, size two tibia, 8 mm polyethylene insert and a size 32 patella. The post-operative period was uneventful and post-operative radiographs demonstrated well aligned components . She was started on a standard TKA rehabilitation protocol with elbow crutch assisted full weight-bearing ambulation from post-operative day 1 for a month. A range of motion (ROM) of 0–125° was achieved by 3 months by which time she was comfortable walking unassisted.\nTwelve months after the index surgery, she presented with the operated knee locked in flexion. She described attempting to stand from a squatting position and falling forwards. Examination revealed moderately swollen knee in 60° of fixed flexion with further flexion to 120°. Neurologic examination was found to be normal. Standard radiographs revealed PKD .\nThe patient was taken to theatre for an examination under anesthesia with a plan for revision if needed. Under general anesthesia, the knee was flexed to maximum to bring the polyethylene post below and parallel to the inferior aspect of the cam and tibia was pulled anteriorly to reduce the knee. After reduction, we attempted to re-dislocate the knee in full flexion with a posteriorly directed force on the proximal tibia . We found the joint to be stable through the entire range of movement in both sagittal and coronal plane and could not be dislocated even on applying a posterior force in full flexion.\nHer range of movement was restored to 0–125° and was mobilized full weight bearing. She had an uneventful recovery at 3 years follow-up.", + "fulltext_subclaims": [ + "The patient is a 71-year-old female.", + "The patient had right knee tri compartmental osteoarthritis.", + "The patient underwent a right TKA.", + "The implant used was a posterior stabilized (PS) fixed bearing cobalt chrome implant.", + "The implant was a PFC Sigma DePuy, Synthes.", + "The surgery was performed through a medial para patellar approach.", + "A combination of measured and gap resection method was used for ligament and flexion/extension balancing.", + "The implant component used was size two femur.", + "The implant component used was size two tibia.", + "The implant component used was an 8 mm polyethylene insert.", + "The implant component used was a size 32 patella.", + "Post-operative radiographs demonstrated well aligned components.", + "The patient was started on a standard TKA rehabilitation protocol.", + "The patient used elbow crutches for full weight-bearing ambulation from post-operative day 1.", + "The patient used elbow crutches for full weight-bearing ambulation for a month.", + "A range of motion of 0–125° was achieved by 3 months.", + "The patient was comfortable walking unassisted by 3 months.", + "Twelve months after the index surgery, the patient presented with the operated knee locked in flexion.", + "The patient described attempting to stand from a squatting position and falling forwards.", + "Examination revealed moderately swollen knee in 60° of fixed flexion.", + "Further flexion to 120° was possible.", + "Standard radiographs revealed PKD.", + "The patient was taken to theatre for an examination under anesthesia.", + "Under general anesthesia, the knee was flexed to maximum to bring the polyethylene post below and parallel to the inferior aspect of the cam.", + "The tibia was pulled anteriorly to reduce the knee.", + "After reduction, the joint was stable through the entire range of movement in both sagittal and coronal plane.", + "The joint could not be dislocated even on applying a posterior force in full flexion.", + "The patient's range of movement was restored to 0–125°.", + "The patient was mobilized full weight bearing.", + "The patient had an uneventful recovery at 3 years follow-up." + ], + "summary": "A 71-year-old female presented with the right posterior knee dislocation following 1 year of TKA. Following the successful relocation, the knee was found to be stable throughout the range of movement and an uneventful recovery at 3 years follow-up.", + "summary_subclaims": [ + "A 71-year-old female presented with the right posterior knee dislocation following 1 year of TKA.", + "Following the successful relocation, the knee was found to be stable throughout the range of movement.", + "An uneventful recovery was noted at 3 years follow-up." + ] + }, + { + "id": "multiclinsum_test_2420_en.txt", + "fulltext": "A 47-year-old man (height of 175.8 cm and weight of 74.8 kg) complained of a tingling sensation in his leg. He had a history of hypertension and asthma in the previous two years, and history of sinus surgery for sinusitis in the previous one year. Ten days before admission, the patient had a tingling sensation in his left leg, from the posterior thigh to the foot. His spinal radiography findings were unspecified. Therefore, the patient was suspected as having a disc herniation, and observation was decided while continuing the medical treatment. Four days before admission, the patient had a tingling sensation that progressed in both legs. The symptoms did not improve, and motor weakness progressed below the ankle. In the physical examination at admission, motor power was grade 5 in the hip flexor and knee extensor in both lower extremities. However, it was grade 0 in the ankle dorsiflexor, and first toe extensor and flexor, and grades 4 and 0 in the ankle plantar flexor on the right and left sides, respectively. Sensory loss was not found in the L1 - L4 dermatomes, yet was 50% on the right side and 0% on the left side for the L5 and S1 dermatomes. He also had a heating sensation in his left foot and no knee-jerk reaction. He showed a weight loss of 6 kg during the last month, and the signal intensity of the bone marrow on L-spine magnetic resonance imaging (MRI) was diffusively reduced to be less than or equal to the disc. These findings indicated a hematologic disease and the possibility of malignancy with little preserved fat marrow. Abdominal and pelvic computed tomography (CT) revealed diffuse wall thickening of the gallbladder with some irregularity. However, the bone marrow biopsy slides showed a generally hyper-cellular (50% to 60%) marrow for the patient’s age, with small hypo-cellular regions (0% to 20%). On aspirate smears, the eosinophil counts were markedly increased, with expanded eosinophil myelocytes and metamyelocytes. The results of the pulmonary function tests showed an obstructive pattern, such as a forced vital capacity of 54%, a forced expiratory volume in one second of 46%, and forced expiratory flow between 25% and 70% of 33% of the predicted values. The findings from a nerve conduction study suggested multiple mono-neuropathies. In addition, his laboratory findings showed peripheral eosinophilia and positivity for myeloperoxidase anti-neutrophil cytoplasmic autoantibody (MPO-ANCA; ). Therefore, CSS was strongly suspected, and steroid and cyclophosphamide therapies were started after nerve biopsy under spinal anesthesia. At that time, the symptoms were progressing to the left wrist drop and both legs. However, nerve biopsy results were consistent with demyelinating peripheral neuropathy. The patient underwent cholecystectomy under general anesthesia to exclude gallbladder cancer, suspected on the basis of CT findings, and pathological confirmation was possible with a gallbladder specimen .", + "fulltext_subclaims": [ + "The patient is a 47-year-old man.", + "The patient's height is 175.8 cm.", + "The patient's weight is 74.8 kg.", + "The patient complained of a tingling sensation in his leg.", + "The patient had a history of hypertension in the previous two years.", + "The patient had a history of asthma in the previous two years.", + "The patient had a history of sinus surgery for sinusitis in the previous one year.", + "Ten days before admission, the patient had a tingling sensation in his left leg, from the posterior thigh to the foot.", + "The patient was suspected as having a disc herniation.", + "Observation was decided while continuing the medical treatment.", + "Four days before admission, the patient had a tingling sensation that progressed in both legs.", + "The symptoms did not improve.", + "Motor weakness progressed below the ankle.", + "In the physical examination at admission, motor power was grade 5 in the hip flexor and knee extensor in both lower extremities.", + "In the physical examination at admission, motor power was grade 0 in the ankle dorsiflexor.", + "In the physical examination at admission, motor power was grade 0 in the first toe extensor and flexor.", + "In the physical examination at admission, motor power was grade 4 in the ankle plantar flexor on the right side.", + "In the physical examination at admission, motor power was grade 0 in the ankle plantar flexor on the left side.", + "Sensory loss was not found in the L1 - L4 dermatomes.", + "Sensory loss was 50% on the right side for the L5 and S1 dermatomes.", + "Sensory loss was 0% on the left side for the L5 and S1 dermatomes.", + "The patient had a heating sensation in his left foot.", + "The patient had no knee-jerk reaction.", + "The patient had a weight loss of 6 kg during the last month.", + "The signal intensity of the bone marrow on L-spine MRI was diffusively reduced to be less than or equal to the disc.", + "These findings indicated a hematologic disease.", + "These findings indicated the possibility of malignancy with little preserved fat marrow.", + "Abdominal and pelvic CT revealed diffuse wall thickening of the gallbladder with some irregularity.", + "The bone marrow biopsy slides showed a generally hyper-cellular (50% to 60%) marrow for the patient’s age.", + "The bone marrow biopsy slides showed small hypo-cellular regions (0% to 20%).", + "On aspirate smears, the eosinophil counts were markedly increased.", + "On aspirate smears, there were expanded eosinophil myelocytes and metamyelocytes.", + "The results of the pulmonary function tests showed an obstructive pattern.", + "The forced vital capacity was 54% of the predicted value.", + "The forced expiratory volume in one second was 46% of the predicted value.", + "The forced expiratory flow between 25% and 70% was 33% of the predicted value.", + "The findings from a nerve conduction study suggested multiple mono-neuropathies.", + "The laboratory findings showed peripheral eosinophilia.", + "The laboratory findings showed positivity for myeloperoxidase anti-neutrophil cytoplasmic autoantibody (MPO-ANCA).", + "CSS was strongly suspected.", + "Steroid therapy was started after nerve biopsy under spinal anesthesia.", + "Cyclophosphamide therapy was started after nerve biopsy under spinal anesthesia.", + "At that time, the symptoms were progressing to the left wrist drop and both legs.", + "The nerve biopsy results were consistent with demyelinating peripheral neuropathy.", + "The patient underwent cholecystectomy under general anesthesia.", + "Cholecystectomy was performed to exclude gallbladder cancer.", + "Pathological confirmation was possible with a gallbladder specimen." + ], + "summary": "A 47-year-old man (height, 175.8 cm and weight, 74.8 kg) complained of a tingling sensation in his leg. He had a history of hypertension and asthma in the previous two years, and history of sinus surgery for sinusitis in the previous one year. He showed weight loss of 6 kg during the last month, and the signal intensity of the bone marrow on magnetic resonance imaging was diffusively reduced to be less than or equal to the disc. These findings indicated a hematologic disease and the possibility of malignancy. However, a nerve conduction study suggested multiple mononeuropathies. In addition, his laboratory findings showed peripheral eosinophilia and positivity for myeloperoxidase anti-neutrophil cytoplasmic autoantibody. Therefore, CSS was strongly suspected.", + "summary_subclaims": [ + "The patient is a 47-year-old man.", + "The patient's height is 175.8 cm.", + "The patient's weight is 74.8 kg.", + "The patient complained of a tingling sensation in his leg.", + "The patient had a history of hypertension in the previous two years.", + "The patient had a history of asthma in the previous two years.", + "The patient had a history of sinus surgery for sinusitis in the previous one year.", + "The patient showed weight loss of 6 kg during the last month.", + "The signal intensity of the bone marrow on magnetic resonance imaging was diffusively reduced to be less than or equal to the disc.", + "These findings indicated a hematologic disease.", + "These findings indicated the possibility of malignancy.", + "A nerve conduction study suggested multiple mononeuropathies.", + "The laboratory findings showed peripheral eosinophilia.", + "The laboratory findings showed positivity for myeloperoxidase anti-neutrophil cytoplasmic autoantibody.", + "CSS was strongly suspected." + ] + }, + { + "id": "multiclinsum_test_160_en.txt", + "fulltext": "A 55-year-old woman presented to our hospital with nonspecific knee pain in the lateral aspect of the right leg. She had no symptoms on the left leg. She had hypertension, diabetes mellitus, and dyslipidemia, and she was on a treatment for intervertebral disc herniation in another hospital. Her physical examination was nonspecific, and the right and left ankle-brachial pressure index was 1.06 and 0.88, respectively.\nThe patient underwent Doppler US examination on bilateral lower extremity arteries and veins to examine potential vascular abnormality. There was no abnormality in vessels of the right side. The left SFA was revealed to be divided into two trunks with similar luminal diameter and courses parallel . They reunited at distal thigh level. No other abnormalities or diseases in vessels of the left side were identified by US examination.\nFor further evaluation, CTA of bilateral lower extremities was performed. The left SFA appeared to originate from left common femoral artery at the same level of the contralateral side. It appeared to run as a single vessel, 4 cm long, then split into two branches, medial and lateral ones. The luminal diameter of the medial one of the SFA was 5.3 mm, whereas that of lateral one was 4.4 mm, measured in each proximal portion . Both then traveled 14 cm distal along anterior side of the left superficial femoral vein. They merged at distal thigh level to form single vessel and ran 4 cm distal to enter the adductor hiatus. The anatomic orientation was well visualized in three-dimensional volume rendering and maximum intensity projection images . There was no evidence of atherosclerotic stenosis or other diseases on the bilateral lower extremity arteries. The findings of US and CTA examination did not correspond with the symptom of the patient, and the patient was discharged.", + "fulltext_subclaims": [ + "A 55-year-old woman presented with nonspecific knee pain in the lateral aspect of the right leg.", + "She had no symptoms on the left leg.", + "She had hypertension, diabetes mellitus, and dyslipidemia.", + "She was on treatment for intervertebral disc herniation in another hospital.", + "The right and left ankle-brachial pressure index was 1.06 and 0.88, respectively.", + "The patient underwent Doppler US examination on bilateral lower extremity arteries and veins.", + "There was no abnormality in vessels of the right side.", + "The left SFA was revealed to be divided into two trunks with similar luminal diameter and courses parallel.", + "The two trunks reunited at distal thigh level.", + "No other abnormalities or diseases in vessels of the left side were identified by US examination.", + "CTA of bilateral lower extremities was performed.", + "The left SFA appeared to originate from the left common femoral artery at the same level of the contralateral side.", + "The left SFA appeared to run as a single vessel, 4 cm long, then split into two branches, medial and lateral ones.", + "The luminal diameter of the medial one of the SFA was 5.3 mm, whereas that of the lateral one was 4.4 mm, measured in each proximal portion.", + "Both branches traveled 14 cm distal along the anterior side of the left superficial femoral vein.", + "The two branches merged at distal thigh level to form a single vessel.", + "The single vessel ran 4 cm distal to enter the adductor hiatus.", + "The anatomic orientation was well visualized in three-dimensional volume rendering and maximum intensity projection images.", + "There was no evidence of atherosclerotic stenosis or other diseases on the bilateral lower extremity arteries.", + "The findings of US and CTA examination did not correspond with the symptom of the patient.", + "The patient was discharged." + ], + "summary": "A 55-year-old woman presented to our hospital with an intermittent cramp in the lateral aspect of the right leg. The patient underwent Doppler US examination on bilateral lower extremity arteries and veins to examine potential vascular abnormality. Incidentally, US discovered the duplicated left SFA and CTA of bilateral lower extremities revealed the anatomic orientation, course, length, diameter and distance of the duplicated left SFA. It was revealed to be divided into two trunks with similar luminal diameter and courses parallel. They reunited at distal thigh level. The findings of US and CTA examination did not correspond with the symptom of the patient, and the patient was discharged.", + "summary_subclaims": [ + "A 55-year-old woman presented to our hospital with an intermittent cramp in the lateral aspect of the right leg.", + "The patient underwent Doppler US examination on bilateral lower extremity arteries and veins.", + "US discovered the duplicated left SFA.", + "CTA of bilateral lower extremities revealed the anatomic orientation, course, length, diameter and distance of the duplicated left SFA.", + "The duplicated left SFA was divided into two trunks with similar luminal diameter.", + "The two trunks of the duplicated left SFA had courses parallel.", + "The two trunks of the duplicated left SFA reunited at distal thigh level.", + "The findings of US and CTA examination did not correspond with the symptom of the patient.", + "The patient was discharged." + ] + }, + { + "id": "multiclinsum_test_3319_en.txt", + "fulltext": "A 51-year-old ambidextrous woman presented with neurofibromatosis type 1 and essential tremor. She was also being followed in psychiatry for a depressive disorder, body image distortion and marked fear of mice.\n\nHis epilepsy began in 2008 with two nocturnal tonic seizures, with initial response to lamotrigine. In 2012, focal seizures with altered consciousness reappeared, without response to eslicarbacepine and levetiracetam. Depressive symptoms persisted.\n\nA preoperative videoelectroencephalographic evaluation suggested a right temporal lobe onset of seizures. A 3T MRI with epilepsy protocol showed a right mesial temporal sclerosis and a positron emission tomography showed a mesial temporal and ipsilateral temporal pole hypomethabolism. There was a visual and auditory-verbal memory impairment in the neuropsychological study. The intracarotid sodium amytal test suggested a memory deficit in the right hippocampus.\n\nIn 2016, a temporal anteromedial resection was performed that included the right amygdala, hippocampus, parahippocampal structures and temporal pole, without new seizures and without antiepileptic treatment for a year. He associated a great mental improvement and the disappearance of the rat phobia he presented.\n", + "fulltext_subclaims": [ + "A 51-year-old ambidextrous woman presented with neurofibromatosis type 1 and essential tremor.", + "She was also being followed in psychiatry for a depressive disorder, body image distortion and marked fear of mice.", + "His epilepsy began in 2008 with two nocturnal tonic seizures, with initial response to lamotrigine.", + "In 2012, focal seizures with altered consciousness reappeared, without response to eslicarbacepine and levetiracetam.", + "A preoperative videoelectroencephalographic evaluation suggested a right temporal lobe onset of seizures.", + "A 3T MRI with epilepsy protocol showed a right mesial temporal sclerosis.", + "A positron emission tomography showed a mesial temporal and ipsilateral temporal pole hypomethabolism.", + "There was a visual and auditory-verbal memory impairment in the neuropsychological study.", + "The intracarotid sodium amytal test suggested a memory deficit in the right hippocampus.", + "In 2016, a temporal anteromedial resection was performed that included the right amygdala, hippocampus, parahippocampal structures and temporal pole.", + "There were no new seizures and no antiepileptic treatment for a year.", + "He associated a great mental improvement and the disappearance of the rat phobia he presented." + ], + "summary": "In the clinical case presented, the patient suffers from a pharmacoresistant focal epilepsy and psychiatric comorbidity (anxiety-depressive syndrome and phobias). In the pre-surgical evaluation, the origin of the crisis was established as the right mesial temporal region, so surgery was performed. In reviews, an improvement in both pathologies was observed after the surgical operation on her epilepsy.\n", + "summary_subclaims": [ + "The patient suffers from a pharmacoresistant focal epilepsy.", + "The patient has psychiatric comorbidity (anxiety-depressive syndrome and phobias).", + "In the pre-surgical evaluation, the origin of the crisis was established as the right mesial temporal region.", + "Surgery was performed.", + "An improvement in both pathologies was observed after the surgical operation on her epilepsy." + ] + }, + { + "id": "multiclinsum_test_1618_en.txt", + "fulltext": "We present a case of 40-year-old building and construction male worker who slipped and fell from a height of three (3) meters and sustained a deep penetrating wound on the right side of the anterior neck a week prior to presenting at our facility. He was apparently working from the above height when he slipped and fell on a sharp piece of iron rod which penetrated deep into the right anterior neck. He quickly pulled the sharp iron rod out when he got up from the floor. According to him, the bleeding was not profuse and stopped when he arrived at the local hospital to search for remedy . He did not have hemiplegia, paraplegia, or quadriplegia when we saw him. He is not known to be hypertensive. He did not take alcohol prior to the fall although he takes alcohol occasionally. He had a left femoral fracture at the age of 24 and a right femoral fracture at the age of 32; both incidences were operated on successfully. On examination at our facility we saw a middle aged man who was conscious and alert but however acutely ill with his neck fixed in cervical collar. General as well as systemic examination did not yield much. All the systems where grossly normal. Neurological examination revealed normal pupils which reacted normally to light. Cranial nerves examination was unremarkable. Power on four limbs as well as reflexes was normal. Digital rectal examination revealed a normal spinster tone. Routine laboratory as well as other ancillary (ECG, CXR, etc.) investigations were normal.\nNeck CT-scan done at the local hospital revealed C2-C4 transverse process fractures on the right side, fracture at the right lamina of C3, and right common carotid artery dissection. CT-scan of the head showed no abnormalities . Explorative three-dimensional reconstruction plain and enhanced scan imaging of the cervical spine, chest, and abdomen done at our facility revealed two segmental stenoses of the right common carotid artery with very pale V1 and V3 segment of the right vertebral artery as well as blockage at V2 segment as well as fracture at the right lamina of C3 and C2-C4 transverse processes with free bone fragments and peripheral soft tissue swelling . The skin at the right anterior cervical region is discontinuous, with adjacent soft tissue swellings and gas accumulation. The bilateral carotid artery sheath lymph nodes slightly enlarged. At the upper lobe of the right lung there were multiple calcifications, some of which were adjacent to the pleura. There was also slight thickening of the left pleura. The heart was not enlarged but we observed slight accumulation of gas in the anterior mediastinum. Multiple low-density lesions were seen in the liver which we think are constant cysts. A working diagnosis of right common carotid artery dissection with C1-C4 fractures was made.\nAfter preoperative education and counselling of the patient as well as the relatives, surgery was scheduled the next day. Intraoperative cerebral angiography showed right carotid artery dissection and right vertebral artery occlusion. There was some reparation at the distal end of the right vertebral artery. The left vertebral artery was however normal. We introduced the guiding catheter guide wire to the proximal end of the right common carotid artery with continued infusion of heparinized saline, after which we introduced a guide wire with a Cordis stent (10 ∗ 60mm) to completely cover the right common carotid artery dissection site with stenosis and released the stent gradually until it completely filled the stenosis area ). We delivered contrast agent into right common carotid artery to make sure it was patent before removing the guiding catheter followed by withdrawal of the femoral arterial sheath. Control contrasted angiograph done revealed stenting was successful . The patient recovered markedly and was discharged home a week after. Scheduled outpatient visit every 6 months for 2 years revealed no neurological complications.", + "fulltext_subclaims": [ + "The patient is a 40-year-old male building and construction worker.", + "He slipped and fell from a height of three (3) meters.", + "He sustained a deep penetrating wound on the right side of the anterior neck a week prior to presenting at the facility.", + "The wound was caused by a sharp piece of iron rod.", + "The iron rod was pulled out when he got up from the floor.", + "The bleeding was not profuse and stopped when he arrived at the local hospital.", + "He did not have hemiplegia, paraplegia, or quadriplegia when seen.", + "He is not known to be hypertensive.", + "He did not take alcohol prior to the fall.", + "He had a left femoral fracture at the age of 24.", + "He had a right femoral fracture at the age of 32.", + "Both femoral fractures were operated on successfully.", + "On examination, he was conscious and alert.", + "The neck was fixed in a cervical collar.", + "General and systemic examination did not yield much.", + "All systems were grossly normal.", + "Neurological examination revealed normal pupils reacting to light.", + "Cranial nerves examination was unremarkable.", + "Power on four limbs and reflexes was normal.", + "Digital rectal examination revealed a normal spinster tone.", + "Routine laboratory investigations were normal.", + "ECG and CXR were normal.", + "A neck CT-scan at the local hospital revealed C2-C4 transverse process fractures on the right side.", + "A neck CT-scan at the local hospital revealed a fracture at the right lamina of C3.", + "A neck CT-scan at the local hospital revealed right common carotid artery dissection.", + "A CT-scan of the head showed no abnormalities.", + "Explorative three-dimensional reconstruction imaging at the facility revealed two segmental stenoses of the right common carotid artery.", + "The V1 and V3 segments of the right vertebral artery were very pale.", + "The V2 segment of the right vertebral artery was blocked.", + "Fractures at the right lamina of C3 and C2-C4 transverse processes were noted.", + "Free bone fragments and peripheral soft tissue swelling were observed.", + "The skin at the right anterior cervical region was discontinuous.", + "Adjacent soft tissue swellings and gas accumulation were observed.", + "Bilateral carotid artery sheath lymph nodes were slightly enlarged.", + "Multiple calcifications were seen in the upper lobe of the right lung.", + "Some calcifications were adjacent to the pleura.", + "Slight thickening of the left pleura was observed.", + "The heart was not enlarged.", + "Slight accumulation of gas in the anterior mediastinum was observed.", + "Multiple low-density lesions were seen in the liver.", + "The working diagnosis was right common carotid artery dissection with C1-C4 fractures.", + "Surgery was scheduled the next day after preoperative education and counseling.", + "Intraoperative cerebral angiography showed right carotid artery dissection.", + "Intraoperative cerebral angiography showed right vertebral artery occlusion.", + "There was some reparation at the distal end of the right vertebral artery.", + "The left vertebral artery was normal.", + "A Cordis stent (10 ∗ 60mm) was introduced to cover the right common carotid artery dissection site.", + "The stent was released gradually until it completely filled the stenosis area.", + "Contrast agent was delivered into the right common carotid artery to ensure it was patent.", + "Control contrasted angiography revealed successful stenting.", + "The patient recovered markedly.", + "The patient was discharged home a week after surgery.", + "Scheduled outpatient visits every 6 months for 2 years revealed no neurological complications." + ], + "summary": "We present a case of 40-year-old building and construction male worker who slipped and fell on an iron rod that resulted in penetrating wound on the right side of the anterior neck a week prior to presenting at our facility. He pulled out the iron rod immediately. Computer tomography angiography (CTA) done revealed C2-C4 transverse process fractures on the right side and a fracture at the right lamina of C3 and right common carotid artery dissection with stenosis. He was successfully treated with stenting via endovascular approach.", + "summary_subclaims": [ + "The patient is a 40-year-old building and construction male worker.", + "He slipped and fell on an iron rod.", + "The fall resulted in a penetrating wound on the right side of the anterior neck.", + "The injury occurred a week prior to presenting at the facility.", + "He pulled out the iron rod immediately.", + "Computer tomography angiography (CTA) was performed.", + "CTA revealed C2-C4 transverse process fractures on the right side.", + "CTA revealed a fracture at the right lamina of C3.", + "CTA revealed a right common carotid artery dissection with stenosis.", + "He was successfully treated with stenting via endovascular approach." + ] + }, + { + "id": "multiclinsum_test_1647_en.txt", + "fulltext": "A 52-year-old immunocompetent Chinese-American man with no significant past medical history, including an absence of chronic diseases, was injured while handling a catfish 10 days prior to admission while working as a fishmonger in a New York City supermarket. He had picked up a live channel catfish (I. punctatus) from a fish tank with his ungloved right hand, after which he was stung in the right nail groove of his thumb by the spine of the catfish. The patient experienced immediate and severe pain at the puncture site. As the day progressed, he developed pain, erythema, and swelling throughout his right thumb. Over the next few days, the patient reported an increase in pain from 1 out of 10 to 7 out of 10 in intensity, with radiation to his right forearm, and progressive erythema and swelling which extended proximally up his right arm. Subsequently, he sought medical attention from his primary care physician, who found the patient to be afebrile and prescribed amoxicillin-clavulanate to treat cellulitis and ibuprofen as needed for pain control. The patient revisited his physician 3 days later with the development of an abscess and no response to the antibiotic while remaining afebrile. The ibuprofen that he was taking for pain control likely served as an anti-pyretic and obscured possible fever. His doctor performed an incision and drainage procedure of the lesion and sent the purulent drainage for wound culture. He then referred the patient to the emergency department for admission and intravenous antibiotics. There, the patient was given 900mg intravenous clindamycin and tetanus immunization, as well as ibuprofen 600mg for pain control.\nUpon admission, the patient reported the pain as 2 out of 10 diffusely in his right thumb. He described the pain as throbbing and intermittent, with radiation to his right forearm. The patient was non-toxic appearing, but in severe pain. Vital signs demonstrated a temperature of 96.9°F (36.1°C), pulse of 62 beats per minute, respiratory rate of 18, and blood pressure of 112/71mmHg. The physical examination was unremarkable aside from an indurated, red, firm 2cm swelling to the medial aspect of his right thumb that was tender to palpation, with surrounding erythema and warmth, and lymphangitic erythematous streaks that tracked medially to his antecubital fossa. The laboratory evaluation was unremarkable, including normal liver and renal panels, except for an elevated white blood cell count (WBC) of 13.2K/uL (80% neutrophils), sedimentation rate of 38mm/hour (reference range 0 to 13), and C-reactive protein of 4.5mg/dL (reference range 0 to 1). X-ray views of the thumb were negative for foreign body and gas . There was no evidence of cortical irregularity or periosteal reaction to suggest osteomyelitis.\nThe patient was initially treated with intravenous tobramycin, oral tetracycline, and intravenous ampicillin-sulbactam. Hydrogen peroxide immersion of his right thumb and wet to dry dressings were used for wound care. One day after admission, the patient’s WBC decreased to 7.8K/uL, and Gram stain from the wound on initial presentation revealed moderate Gram-negative bacilli and a few Gram-positive cocci in pairs. Ampicillin-sulbactam was continued and vancomycin was added for possible methicillin-resistant Staphylococcus aureus coverage. After substantial relief of symptoms and reduced signs, including less erythema and induration, and normalization of the WBC, the patient was discharged and prescribed a 10-day course of oral ciprofloxacin and amoxicillin-clavulanate. Wound cultures obtained by his primary care physician grew many Proteus vulgaris and Morganella morganii. Table shows the antimicrobial susceptibility data of the two case isolates. Both organisms, while susceptible to ciprofloxacin, with minimum inhibitory concentration (MIC) less than 0.25μg/mL, were resistant to ampicillin, with MIC greater than 32μg/mL. At a 12-month telephone follow-up, the patient denied developing further symptoms and reported that the wound had healed completely without complication.", + "fulltext_subclaims": [ + "The patient is a 52-year-old immunocompetent Chinese-American man.", + "He had no significant past medical history, including an absence of chronic diseases.", + "He was injured while handling a catfish 10 days prior to admission.", + "He was working as a fishmonger in a New York City supermarket.", + "He picked up a live channel catfish (I. punctatus) from a fish tank with his ungloved right hand.", + "He was stung in the right nail groove of his thumb by the spine of the catfish.", + "He experienced immediate and severe pain at the puncture site.", + "Over the next few days, the patient reported an increase in pain from 1 out of 10 to 7 out of 10 in intensity.", + "The pain radiated to his right forearm.", + "The erythema and swelling extended proximally up his right arm.", + "He sought medical attention from his primary care physician.", + "The patient was found to be afebrile.", + "He was prescribed amoxicillin-clavulanate to treat cellulitis.", + "He was prescribed ibuprofen as needed for pain control.", + "He revisited his physician 3 days later with the development of an abscess.", + "He had no response to the antibiotic while remaining afebrile.", + "The ibuprofen that he was taking for pain control likely served as an anti-pyretic and obscured possible fever.", + "His doctor performed an incision and drainage procedure of the lesion.", + "The purulent drainage was sent for wound culture.", + "He was referred to the emergency department for admission and intravenous antibiotics.", + "He was given 900mg intravenous clindamycin.", + "He received tetanus immunization.", + "He was given ibuprofen 600mg for pain control.", + "Upon admission, the patient reported the pain as 2 out of 10 diffusely in his right thumb.", + "The pain was described as throbbing and intermittent.", + "The pain radiated to his right forearm.", + "The patient was non-toxic appearing, but in severe pain.", + "Vital signs demonstrated a temperature of 96.9°F (36.1°C).", + "The physical examination was unremarkable aside from an indurated, red, firm 2cm swelling to the medial aspect of his right thumb.", + "The swelling was tender to palpation.", + "There was surrounding erythema and warmth.", + "There were lymphangitic erythematous streaks that tracked medially to his antecubital fossa.", + "The laboratory evaluation was unremarkable, including normal liver and renal panels.", + "The white blood cell count (WBC) was 13.2K/uL.", + "The sedimentation rate was 38mm/hour.", + "The C-reactive protein was 4.5mg/dL.", + "X-ray views of the thumb were negative for foreign body and gas.", + "There was no evidence of cortical irregularity or periosteal reaction to suggest osteomyelitis.", + "The patient was initially treated with intravenous tobramycin.", + "He received oral tetracycline.", + "He received intravenous ampicillin-sulbactam.", + "Hydrogen peroxide immersion of his right thumb was used for wound care.", + "Wet to dry dressings were used for wound care.", + "One day after admission, the patient’s WBC decreased to 7.8K/uL.", + "Gram stain from the wound on initial presentation revealed moderate Gram-negative bacilli.", + "Gram stain from the wound on initial presentation revealed a few Gram-positive cocci in pairs.", + "Ampicillin-sulbactam was continued.", + "Vancomycin was added for possible methicillin-resistant Staphylococcus aureus coverage.", + "After substantial relief of symptoms and reduced signs, the patient was discharged.", + "The patient was prescribed a 10-day course of oral ciprofloxacin.", + "The patient was prescribed a 10-day course of amoxicillin-clavulanate.", + "Wound cultures obtained by his primary care physician grew many Proteus vulgaris.", + "Wound cultures obtained by his primary care physician grew many Morganella morganii.", + "Both organisms were susceptible to ciprofloxacin, with minimum inhibitory concentration (MIC) less than 0.25μg/mL.", + "Both organisms were resistant to ampicillin, with MIC greater than 32μg/mL.", + "At a 12-month telephone follow-up, the patient denied developing further symptoms.", + "The wound had healed completely without complication." + ], + "summary": "A 52-year-old Chinese-American man was hospitalized with erythema and swelling of his right arm of 10 days' duration after skin penetration by a catfish barb. An abscess of his right thumb had undergone incision and drainage, with purulent drainage sent for wound culture immediately prior to admission. Laboratory studies revealed elevated white blood count, sedimentation rate, and C-reactive protein. The patient was treated with intravenous ampicillin-sulbactam and vancomycin during his hospitalization, and symptoms improved. Wound cultures obtained prior to presentation grew many Proteus vulgaris and Morganella morganii. He was subsequently discharged on a 10-day course of oral ciprofloxacin and amoxicillin-clavulanate. At a 12-month telephone follow-up, the patient denied developing further symptoms and reported that the wound had healed completely without complication.", + "summary_subclaims": [ + "The patient was a 52-year-old Chinese-American man.", + "He was hospitalized with erythema and swelling of his right arm.", + "The symptoms had lasted 10 days.", + "The symptoms followed skin penetration by a catfish barb.", + "An abscess of his right thumb had undergone incision and drainage.", + "Purulent drainage was sent for wound culture immediately prior to admission.", + "Laboratory studies revealed elevated white blood count.", + "Laboratory studies revealed elevated sedimentation rate.", + "Laboratory studies revealed elevated C-reactive protein.", + "The patient was treated with intravenous ampicillin-sulbactam.", + "The patient was treated with intravenous vancomycin.", + "Symptoms improved during hospitalization.", + "Wound cultures obtained prior to presentation grew many Proteus vulgaris.", + "Wound cultures obtained prior to presentation grew many Morganella morganii.", + "He was discharged on a 10-day course of oral ciprofloxacin.", + "He was discharged on a 10-day course of oral amoxicillin-clavulanate.", + "At a 12-month telephone follow-up, the patient denied developing further symptoms.", + "At a 12-month telephone follow-up, the patient reported that the wound had healed completely without complication." + ] + }, + { + "id": "multiclinsum_test_3285_en.txt", + "fulltext": "A 37-year-old Thai woman presented with a 1-year history of painless proptosis of the left eye and complaints of diplopia during up gaze. She denied any previous history of trauma, underlying disease, or genetic disease in the family. Physical examination showed mild swelling of the left eyelid and a yellowish subconjunctival mass in the superior bulbar region, which had a soft consistency, was non-reducible, and had no apparent posterior limit. The best-corrected visual acuity (BCVA) was 20/20 bilaterally. The intraocular pressures were 14 mmHg in the right eye and 15 mmHg in the left eye. Extraocular movements were full for the right eye and limited in elevation for the left eye. The globe was displaced inferiorly by 5 mm, and proptosis of 5 mm was observed in the left eye. Hertel exophthalmometry of 10 right eye and 15 left eye with a base of 107 mm. Magnetic resonance imaging of the brain and orbits demonstrated a soft tissue mass with dimensions of 1.1×1.6 x 1.7 cm involving the superior rectus muscle belly and tendon. The lesion showed hyperintensity on T1- and T2-weighted images. The mass was saturated on fat-saturated sequences and suppressible on sequences with fat suppression. It was responsible for the left eye proptosis and inferior globe displacement.\n\nThe superior bulbar mass gradually enlarged and prolapsed in the palpebral fissure over 4 months. A debulking procedure via a transconjunctival and vertical lid split was performed. An ovoid well-circumscribed yellowish mass was found at the superior rectus muscle in the sub-tenon and intraorbital spaces. A pathological study revealed mature adipose tissue, with minimal connective tissue stroma, enclosed in a thin fibrous capsule. The tenon capsule showed multiple foci of small lymphoid cells and plasma cell aggregates. The immunostaining results for CD3, CD5, CD10, CD20, CD23, cyclin D1, BCL2, kappa, lambda, immunoglobulin (Ig) G (IgG), IgG4, IgA, and IgM were consistent with chronic non-specific inflammation. Systemic steroid treatment (prednisolone 1 mg/kg/day) was initiated and maintained for 1 month. The BCVA last follow-up was 20/20. The proptosis and diplopia improved 3 months after treatment.", + "fulltext_subclaims": [ + "The patient is a 37-year-old Thai woman.", + "She had a 1-year history of painless proptosis of the left eye.", + "She had complaints of diplopia during up gaze.", + "She denied any previous history of trauma.", + "She denied any underlying disease.", + "She denied any genetic disease in the family.", + "Physical examination showed mild swelling of the left eyelid.", + "A yellowish subconjunctival mass was present in the superior bulbar region.", + "The mass had a soft consistency.", + "The mass was non-reducible.", + "The mass had no apparent posterior limit.", + "The best-corrected visual acuity was 20/20 bilaterally.", + "The intraocular pressure was 14 mmHg in the right eye.", + "The intraocular pressure was 15 mmHg in the left eye.", + "Extraocular movements were full for the right eye.", + "Extraocular movements were limited in elevation for the left eye.", + "The globe was displaced inferiorly by 5 mm.", + "Proptosis of 5 mm was observed in the left eye.", + "Hertel exophthalmometry showed 10 right eye and 15 left eye.", + "Magnetic resonance imaging showed a soft tissue mass involving the superior rectus muscle belly and tendon.", + "The lesion showed hyperintensity on T1- and T2-weighted images.", + "The mass was saturated on fat-saturated sequences.", + "The mass was suppressible on sequences with fat suppression.", + "The mass was responsible for the left eye proptosis.", + "The mass caused inferior globe displacement.", + "The superior bulbar mass gradually enlarged and prolapsed in the palpebral fissure over 4 months.", + "A debulking procedure via a transconjunctival and vertical lid split was performed.", + "An ovoid well-circumscribed yellowish mass was found at the superior rectus muscle.", + "The mass was located in the sub-tenon and intraorbital spaces.", + "A pathological study revealed mature adipose tissue.", + "The adipose tissue had minimal connective tissue stroma.", + "The tissue was enclosed in a thin fibrous capsule.", + "The tenon capsule showed multiple foci of small lymphoid cells and plasma cell aggregates.", + "The immunostaining results were consistent with chronic non-specific inflammation.", + "Systemic steroid treatment (prednisolone 1 mg/kg/day) was initiated.", + "The treatment was maintained for 1 month.", + "The best-corrected visual acuity at last follow-up was 20/20.", + "The proptosis improved 3 months after treatment.", + "The diplopia improved 3 months after treatment." + ], + "summary": "We report a case of a 37-year-old woman who presented with chronic progressive proptosis and inferior globe displacement of left eye. External eye examination revealed a yellowish mass at the superior bulbar conjunctiva. Magnetic resonance imaging showed a well-circumscribed mass confined in the superior rectus muscle belly and tendon with a fat signal. Debulking surgery was performed using the transconjunctival and vertical lid split approach. A pathological study demonstrated matured adipose tissue cells encapsulated by a thin layer of fibrous tissue, in addition to the chronic non-specific inflammation of the tenon capsule tissue sample. Histopathological findings of the mass were consistent with a well-circumscribed intramuscular lipoma. The symptoms of the patient were significantly improved 3 months after surgical and short-course systemic steroid treatments. However, long-term surveillance is needed.", + "summary_subclaims": [ + "The patient was a 37-year-old woman.", + "She presented with chronic progressive proptosis and inferior globe displacement of the left eye.", + "External eye examination revealed a yellowish mass at the superior bulbar conjunctiva.", + "Magnetic resonance imaging showed a well-circumscribed mass confined in the superior rectus muscle belly and tendon with a fat signal.", + "Debulking surgery was performed using the transconjunctival and vertical lid split approach.", + "A pathological study demonstrated matured adipose tissue cells encapsulated by a thin layer of fibrous tissue.", + "The histopathological findings of the mass were consistent with a well-circumscribed intramuscular lipoma.", + "The symptoms of the patient were significantly improved 3 months after surgical and short-course systemic steroid treatments.", + "Long-term surveillance is needed." + ] + }, + { + "id": "multiclinsum_test_700_en.txt", + "fulltext": "The patient experienced rapid decreases in hemoglobin and platelet levels for 3 months.\nPast treatment for blood diseases: Twelve years earlier, a 51-year-old Chinese man was diagnosed with acquired aplastic anemia (AA) in several blood disease centers due to gradually aggravated fatigue. He was prescribed cyclosporine and stanozolol, achieving significant hematological improvement.\nThree years ago, the patient developed evident hemoglobinuria and was diagnosed with PNH based on increased marrow cellularity and a significant decrease in cluster of differentiation (CD)55 and CD59 expression on erythrocytes and granulocytes. Cyclosporine and stanozolol were tapered off, and antiplatelet drugs became his main treatment. During the three years of PNH history, his complete blood count (CBC) results fluctuated within the following range: White blood cell (WBC) count, 5.50–7.50 × 109/L; red blood cell (RBC) count, 2.90-3.30 × 1012/L; hemoglobin (Hb) level, 80-100 g/L; and platelet (Plt) count, 170-230 × 109/L.\nThree months earlier, the patient’s hemoglobinuria worsened, and he initiated oral administration of methylprednisolone at a dose of 8 mg/d and sodium bicarbonate at a dose of 1.0 g three times per day at another hospital to alleviate complement-mediated hemolysis.\nRapid decreases in hemoglobin and platelet levels following GC treatment: Before methylprednisolone treatment, the patient’s CBC showed the following results: WBC count, 6.73 × 109/L; RBC count, 3.15 × 1012/L; Hb level, 85 g/L; Plt count, 195 × 109/L; and absolute reticulocyte (Ret) count, 290.2 × 109/L. Following GC treatment, the patient’s fatigue worsened, and headache, palpitation and dyspnea symptoms emerged and worsened. Seven days after initiating methylprednisolone treatment, his CBC showed the following results: WBC count, 5.28 × 109/L; RBC count, 2.73 × 1012/L; Hb level, 70 g/L; Plt count, 106 ×109/L; and Ret count, 283.3 × 109/L. From that time, intermittent transfusion of packed RBCs was initiated, and the dose of methylprednisolone was increased to 20 mg/d. Along with the increase in methylprednisolone dose, his Hb level and Plt count further decreased, and the frequency of blood transfusion increased. Four days before presenting at our center, the patient’s fatigue was severe with intolerable palpitations and dyspnea.\nThe patient had no history of diseases in hematological, immunological or other systems before the diagnosis of AA.\nThe patient had no family history of inherited, hematological, autoimmune or malignant diseases.\nThe physical examination results of the patient were as follows: height of 171 cm; body weight of 70 kg; body temperature of 36.1 °C; breathing rate of 19 breaths per minute; heart rate of 90 beats per minute; and blood pressure of 130/90 mmHg. Physical examination revealed the presence of a pale face and conjunctiva in the absence of conspicuous mucocutaneous hemorrhage, jaundice and exanthemata. No significant signs of nervous system, respiratory system, cardiovascular system, gastrointestinal system, urogenital system or skeletal musculature system abnormalities were found.\nRoutine laboratory examinations: On admission, the patient’s CBC showed the following results: WBC count, 4.75 × 109/L; RBC count, 1.72 × 1012/L; Hb level, 65 g/L; Plt count, 98 × 109/L; and Ret count, 274.90 × 109/L. The coagulation profile was within the normal limits with a D-dimer level of 0.77 mg/L. Urine examination revealed occult blood of 3+ and protein of 1+. Biochemical analysis revealed elevated serum levels of conjugated bilirubin (10.4 μmol/L), unconjugated bilirubin (24.4 μmol/L), lactate dehydrogenase (LDH, 3349 U/L) and hydroxybutyric dehydrogenase (HBDH, 2695 U/L) in the absence of abnormalities in hepatic and renal functions. The results for hepatitis A, B, and C viruses as well as human immunodeficiency virus were negative. Various antinuclear antibodies and biomarkers of neoplasms were also negative.\nSpecific laboratory examinations for blood diseases: Morphological examination of the marrow smears revealed increased cellularity with a significantly increased percentage of erythroid precursors in the absence of evident dysplastic features . Bone marrow biopsy confirmed the increased cellularity and increased erythropoiesis. Coomb’s test was negative. Significantly decreased CD55 and CD59 expression on erythrocytes (11.24% and 7.80%) and granulocytes (40.26% and 37.35%) was identified by flow cytometric analysis. Decreased serum levels of complement C3 but not C4 were detected. Serum levels of ferritin were slightly decreased, and serum levels of folic acid and vitamin B12 were within the normal limits. Anti-erythrocyte and anti-platelet antibodies were undetectable. Myeloid neoplasm-associated gene mutations were also undetectable.\nNo evident abnormalities were found in the patient’s chest and abdominal computed tomography scans.", + "fulltext_subclaims": [ + "The patient experienced rapid decreases in hemoglobin and platelet levels for 3 months.", + "Twelve years earlier, a 51-year-old Chinese man was diagnosed with acquired aplastic anemia (AA) in several blood disease centers.", + "He was prescribed cyclosporine and stanozolol.", + "He achieved significant hematological improvement.", + "Three years ago, the patient developed evident hemoglobinuria.", + "The patient was diagnosed with PNH based on increased marrow cellularity and a significant decrease in CD55 and CD59 expression on erythrocytes and granulocytes.", + "Cyclosporine and stanozolol were tapered off.", + "Antiplatelet drugs became his main treatment.", + "During the three years of PNH history, his CBC results fluctuated within the following range: WBC count, 5.50–7.50 × 109/L; RBC count, 2.90-3.30 × 1012/L; Hb level, 80-100 g/L; and Plt count, 170-230 × 109/L.", + "Three months earlier, the patient’s hemoglobinuria worsened.", + "He initiated oral administration of methylprednisolone at a dose of 8 mg/d.", + "He initiated oral administration of sodium bicarbonate at a dose of 1.0 g three times per day.", + "Before methylprednisolone treatment, the patient’s CBC showed WBC count of 6.73 × 109/L.", + "Before methylprednisolone treatment, the patient’s CBC showed RBC count of 3.15 × 1012/L.", + "Before methylprednisolone treatment, the patient’s CBC showed Hb level of 85 g/L.", + "Before methylprednisolone treatment, the patient’s CBC showed Plt count of 195 × 109/L.", + "Before methylprednisolone treatment, the patient’s CBC showed absolute reticulocyte count of 290.2 × 109/L.", + "Seven days after initiating methylprednisolone treatment, his CBC showed WBC count of 5.28 × 109/L.", + "Seven days after initiating methylprednisolone treatment, his CBC showed RBC count of 2.73 × 1012/L.", + "Seven days after initiating methylprednisolone treatment, his CBC showed Hb level of 70 g/L.", + "Seven days after initiating methylprednisolone treatment, his CBC showed Plt count of 106 × 109/L.", + "Seven days after initiating methylprednisolone treatment, his CBC showed reticulocyte count of 283.3 × 109/L.", + "The dose of methylprednisolone was increased to 20 mg/d.", + "Along with the increase in methylprednisolone dose, his Hb level and Plt count further decreased.", + "The frequency of blood transfusion increased.", + "Four days before presenting at our center, the patient’s fatigue was severe with intolerable palpitations and dyspnea.", + "The patient had no history of diseases in hematological, immunological or other systems before the diagnosis of AA.", + "The patient had no family history of inherited, hematological, autoimmune or malignant diseases.", + "The physical examination results of the patient were as follows: height of 171 cm; body weight of 70 kg; body temperature of 36.1 °C; breathing rate of 19 breaths per minute; heart rate of 90 beats per minute; and blood pressure of 130/90 mmHg.", + "Physical examination revealed the presence of a pale face and conjunctiva.", + "No significant signs of nervous system, respiratory system, cardiovascular system, gastrointestinal system, urogenital system or skeletal musculature system abnormalities were found.", + "On admission, the patient’s CBC showed WBC count of 4.75 × 109/L.", + "On admission, the patient’s CBC showed RBC count of 1.72 × 1012/L.", + "On admission, the patient’s CBC showed Hb level of 65 g/L.", + "On admission, the patient’s CBC showed Plt count of 98 × 109/L.", + "On admission, the patient’s CBC showed reticulocyte count of 274.90 × 109/L.", + "The coagulation profile was within the normal limits with a D-dimer level of 0.77 mg/L.", + "Urine examination revealed occult blood of 3+.", + "Urine examination revealed protein of 1+.", + "Biochemical analysis revealed elevated serum levels of conjugated bilirubin (10.4 μmol/L).", + "Biochemical analysis revealed elevated serum levels of unconjugated bilirubin (24.4 μmol/L).", + "Biochemical analysis revealed elevated serum levels of lactate dehydrogenase (3349 U/L).", + "Biochemical analysis revealed elevated serum levels of hydroxybutyric dehydrogenase (2695 U/L).", + "The results for hepatitis A, B, and C viruses as well as human immunodeficiency virus were negative.", + "Various antinuclear antibodies and biomarkers of neoplasms were also negative.", + "Morphological examination of the marrow smears revealed increased cellularity.", + "Morphological examination of the marrow smears revealed a significantly increased percentage of erythroid precursors.", + "Bone marrow biopsy confirmed the increased cellularity and increased erythropoiesis.", + "Coomb’s test was negative.", + "Significantly decreased CD55 and CD59 expression on erythrocytes (11.24% and 7.80%) and granulocytes (40.26% and 37.35%) was identified by flow cytometric analysis.", + "Decreased serum levels of complement C3 but not C4 were detected.", + "Serum levels of ferritin were slightly decreased.", + "Serum levels of folic acid and vitamin B12 were within the normal limits.", + "Anti-erythrocyte and anti-platelet antibodies were undetectable.", + "Myeloid neoplasm-associated gene mutations were also undetectable.", + "No evident abnormalities were found in the patient’s chest and abdominal computed tomography scans." + ], + "summary": "An elderly Chinese man had a 12-year history of aplastic anemia (AA) and a 3-year history of paroxysmal nocturnal hemoglobinuria (PNH). Three months earlier, methylprednisolone treatment was initiated at 8 mg/d and increased to 20 mg/d to alleviate complement-mediated hemolysis. Following GC treatment, his platelet counts and hemoglobin levels rapidly decreased. After admission to our hospital, the dose of methylprednisolone was increased to 60 mg/d in an attempt to enhance the suppressive effect. However, increasing the GC dose did not alleviate hemolysis, and his cytopenia worsened. Morphological evaluation of the marrow smears revealed increased cellularity with an increased percentage of erythroid progenitors without evident dysplasia. Cluster of differentiation (CD)55 and CD59 expression was significantly decreased on erythrocytes and granulocytes. In the following days, platelet transfusion was required due to severe thrombocytopenia. Observation of platelet transfusion refractoriness indicated that the exacerbated cytopenia may have been caused by the development of TMA due to GC treatment because the transfused platelet concentrates had no defects in glycosylphosphatidylinositol-anchored proteins. We examined blood smears and found a small number of schistocytes, dacryocytes, acanthocytes and target cells. Discontinuation of GC treatment resulted in rapidly increased platelet counts and steady increases in hemoglobin levels. The patient's platelet counts and hemoglobin levels returned to the levels prior to GC treatment 4 weeks after GC discontinuation.", + "summary_subclaims": [ + "The patient had a 12-year history of aplastic anemia.", + "The patient had a 3-year history of paroxysmal nocturnal hemoglobinuria.", + "Methylprednisolone treatment was initiated at 8 mg/d.", + "The methylprednisolone dose was increased to 20 mg/d.", + "Following GC treatment, platelet counts and hemoglobin levels rapidly decreased.", + "The methylprednisolone dose was increased to 60 mg/d.", + "Increasing the GC dose did not alleviate hemolysis.", + "Cytopenia worsened after increasing the GC dose.", + "Marrow smears showed increased cellularity with an increased percentage of erythroid progenitors.", + "CD55 and CD59 expression was significantly decreased on erythrocytes and granulocytes.", + "Platelet transfusion was required due to severe thrombocytopenia.", + "Platelet transfusion refractoriness was observed.", + "Exacerbated cytopenia may have been caused by the development of TMA due to GC treatment.", + "Blood smears showed a small number of schistocytes, dacryocytes, acanthocytes, and target cells.", + "Discontinuation of GC treatment resulted in rapidly increased platelet counts.", + "Hemoglobin levels steadily increased after GC discontinuation.", + "Platelet counts and hemoglobin levels returned to pre-GC treatment levels 4 weeks after GC discontinuation." + ] + }, + { + "id": "multiclinsum_test_2061_en.txt", + "fulltext": "A 31-year-old male patient presented to the hospital with a progressively growing mass in the right lower abdomen, along with abdominal discomfort. Symptoms are discovered 1 week before admission. Prior to seeking care at our facility, the patient had undergone abdominal CT imaging at a community hospital, which revealed the presence of an abdominal mass. An abdominal CT scan revealed a well-defined mass measuring 3.9*2.9 cm, located anterior to the right psoas muscle at the level of the external iliac vessels . Enteroscopy revealed no evidence of colonic abnormalities, and blood tests did not indicate any abnormalities.\nDuring exploratory laparotomy, the mass was identified in the distal ileum, exhibiting clear margins, firm consistency, and a maximum diameter of 4 cm. However, the nature of the mass could not be determined during surgery. Consequently, partial resection of the ileum and cecum was performed, followed by ileocolonic end-to-end anastomosis, with no postoperative complications.\nGross examination of the resected specimen revealed a grey-white nodular mass measuring approximately 4*3*5 cm, characterized by a firm and scar-like consistency . Histologically, the mass extended from the submucosal layer to the serosa of the distal ileum, infiltrating and growing within the intestinal wall and adipose tissue, displaying a fascicular or woven pattern arrangement. The spindle-shaped cells exhibited abundant cytoplasm, elongated nuclei with wavy features, interspersed with collagen fibers, and minimal infiltration of inflammatory cells (, ).\nImmunohistochemical analysis demonstrated diffuse nuclear expression of β-catenin , along with nuclear positivity for vimentin (Vim), smooth muscle actin (SMA), and desmin (Des). The mass was negative for CD34, DOG-1, S-100, ENA, actin, and S-100. The final pathological diagnosis confirmed primary DF of the distal ileum (invasive fibromatosis).\nUpon discharge from hospital, our patient had demonstrated clinical improvement and stability following surgery. Based on our findings, we recommend a regular follow-up schedule for patients. This includes appointments every 3 months during the first year post-surgery, followed by appointments every 6 months for the next 5 years, and then annual appointments thereafter. The follow-up examinations should encompass collection of medical history, physical examination, blood tests, ultrasounds, and CT scans, among other assessments. No additional treatment was administered after surgery, and the patient remained disease-free during the first year of follow-up.", + "fulltext_subclaims": [ + "The patient is a 31-year-old male.", + "The patient presented with a progressively growing mass in the right lower abdomen.", + "The patient had abdominal discomfort.", + "Symptoms were discovered 1 week before admission.", + "The patient had undergone abdominal CT imaging at a community hospital.", + "The abdominal CT scan revealed a well-defined mass measuring 3.9*2.9 cm.", + "The mass was located anterior to the right psoas muscle at the level of the external iliac vessels.", + "Enteroscopy revealed no evidence of colonic abnormalities.", + "Blood tests did not indicate any abnormalities.", + "During exploratory laparotomy, the mass was identified in the distal ileum.", + "The mass had clear margins.", + "The mass had a firm consistency.", + "The mass had a maximum diameter of 4 cm.", + "The nature of the mass could not be determined during surgery.", + "Partial resection of the ileum and cecum was performed.", + "Ileocolonic end-to-end anastomosis was performed.", + "There were no postoperative complications.", + "Gross examination of the resected specimen revealed a grey-white nodular mass measuring approximately 4*3*5 cm.", + "The mass had a firm and scar-like consistency.", + "Histologically, the mass extended from the submucosal layer to the serosa of the distal ileum.", + "The mass infiltrated and grew within the intestinal wall and adipose tissue.", + "The mass displayed a fascicular or woven pattern arrangement.", + "The spindle-shaped cells exhibited abundant cytoplasm.", + "The spindle-shaped cells had elongated nuclei with wavy features.", + "The mass was interspersed with collagen fibers.", + "There was minimal infiltration of inflammatory cells.", + "Immunohistochemical analysis demonstrated diffuse nuclear expression of β-catenin.", + "The mass was positive for nuclear vimentin.", + "The mass was positive for nuclear smooth muscle actin.", + "The mass was positive for nuclear desmin.", + "The mass was negative for CD34.", + "The mass was negative for DOG-1.", + "The mass was negative for S-100.", + "The mass was negative for ENA.", + "The mass was negative for actin.", + "The mass was negative for S-100.", + "The final pathological diagnosis confirmed primary DF of the distal ileum.", + "The patient had demonstrated clinical improvement and stability following surgery.", + "The patient remained disease-free during the first year of follow-up.", + "No additional treatment was administered after surgery.", + "Follow-up appointments are recommended every 3 months during the first year post-surgery.", + "Follow-up appointments are recommended every 6 months for the next 5 years.", + "Follow-up appointments are recommended annually thereafter.", + "Follow-up examinations should include collection of medical history.", + "Follow-up examinations should include physical examination.", + "Follow-up examinations should include blood tests.", + "Follow-up examinations should include ultrasounds.", + "Follow-up examinations should include CT scans." + ], + "summary": "A 31-year-old male patient presented to the hospital with a progressively growing mass in the right lower abdomen, accompanied by abdominal discomfort. Symptoms are discovered 1 week before admission. Enteroscopy revealed no evidence of colonic abnormalities, and blood tests did not indicate any abnormalities. Due to the indeterminate nature of the mass during surgery, a partial resection of the ileum and cecum was performed, followed by ileocolonic end-to-end anastomosis, with no postoperative complications. The final pathological diagnosis confirmed primary desmoid-type fibromatosis of the distal ileum (invasive fibromatosis). To effectively manage DF, we recommend a follow-up schedule for patients. This includes appointments every 3 months in the first year following surgery, followed by appointments every 6 months up to the fifth year, and then once a year thereafter. The follow-up examinations should include collection of the patient's medical history, physical examination, blood tests, ultrasounds, CT scans, and other relevant assessments. During the first year of the follow-up period, no further treatment was administered, and the patient remained disease-free.", + "summary_subclaims": [ + "A 31-year-old male patient presented to the hospital with a progressively growing mass in the right lower abdomen.", + "The mass was accompanied by abdominal discomfort.", + "Symptoms were discovered 1 week before admission.", + "Enteroscopy revealed no evidence of colonic abnormalities.", + "Blood tests did not indicate any abnormalities.", + "A partial resection of the ileum and cecum was performed.", + "An ileocolonic end-to-end anastomosis was performed.", + "There were no postoperative complications.", + "The final pathological diagnosis confirmed primary desmoid-type fibromatosis of the distal ileum.", + "The follow-up schedule includes appointments every 3 months in the first year following surgery.", + "The follow-up schedule includes appointments every 6 months up to the fifth year.", + "The follow-up schedule includes appointments once a year thereafter.", + "Follow-up examinations should include collection of the patient's medical history.", + "Follow-up examinations should include physical examination.", + "Follow-up examinations should include blood tests.", + "Follow-up examinations should include ultrasounds.", + "Follow-up examinations should include CT scans.", + "Follow-up examinations should include other relevant assessments.", + "During the first year of the follow-up period, no further treatment was administered.", + "The patient remained disease-free during the first year of the follow-up period." + ] + }, + { + "id": "multiclinsum_test_102_en.txt", + "fulltext": "A previously healthy, 33-year-old white female was presented with headache and fever for 3 days. She did not used to smoke or consume alcohol. She gave 3 live healthy births and 1 year ago bilateral leg swellings and high blood pressure were noticed close to her last delivery, but medical investigation was not performed and her symptoms disappeared soon after the delivery. Her mother succumbed to a sudden disease, which was characterized by acute renal and neurological injuries, but further information was not available.\nOn physical examination, she was good on appearance, and temperature, blood pressure, and pulse rate were 38°C, 160/100 mmHg, and 110 bpm, respectively. Bilateral minimal pretibial edema was noticed.\nThe laboratory tests were consistent with thrombotic microangiopathy and severe renal dysfunction (leukocytes 5800 cells/mm3, urea 255 mg/dL, creatinine 11.8 mg/dL, uric acid 8.7 mg/dL, Na 133 mEq/L, K 4.9 mEq/L, AST 43 U/L, ALT 105 U/L, LDH 1248 U/L, total bilirubin 0.03 mg/dL, CPK 37 U/L, C-reactive protein <3 mg/L, 2–3 leukocytes and 8–10 erythrocytes per high power field and 3+ proteinuria in urinalysis, 24 hours proteinuria 2.4 g, serum haptoglobin <10 mg/dL, Coomb tests negative, reticulocytes 3.68%, and 5% schistocytes per field in peripheral blood film). Plasma ADAMTS13 levels and activity were within the normal limits. Antinuclear antibody was negative, C3 level was 80 mg/dL (85–200), and C4 level was within the normal range. Left renal agenesis and enlarged right kidney (145 × 55 mm) were detected by urinary ultrasonography.\nGenetic analysis revealed a novel mutation in exon 21 of complement factor H (CFH) (c.3454T>A; p.C1152S), and the same mutation was later identified in her asymptomatic 3 (males) of 4 siblings.\nDaily plasma exchange using 40 mL/kg fresh frozen plasma and on-demand hemodialysis were started. Markers of thrombotic microangiopathy did not consistently normalize during 22 sessions of plasma exchange; therefore, PE was replaced by eculizumab within 2 weeks of vaccination against Neisseria meningitides (900 mg/week for 4 weeks, 1200 mg every other week from the 5th week on). Thrombocytopenia and elevated LDH normalized within 1 month along with gradual improvement in renal functions and the need for dialysis was eliminated within 2 months of eculizumab treatment . Eculizumab was discontinued after 1 year of treatment, during which creatinine nadir was 1.35 mg/dL, and the patient was set to follow-up. Thrombocytes dropped and remained below the lower limit of normal from the 7th month (January 6, 2015) of follow-up on, but LDH levels remained around the upper limit of normal . Multiple peripheral blood films, serum haptoglobin levels, and reticulocyte counts were found normal, except for thrombocytopenia, since detection of thrombocytopenia. Levels of creatinine slightly increased but remained <2 mg/dL except for a few occasions, whereas the levels of proteinuria remained <0.5 g/day (385 mg/day at last visit) . Informed consent was obtained from the patient.", + "fulltext_subclaims": [ + "The patient was a previously healthy, 33-year-old white female.", + "She had headache and fever for 3 days.", + "She did not use to smoke or consume alcohol.", + "She had 3 live healthy births.", + "Bilateral leg swellings and high blood pressure were noticed close to her last delivery.", + "Medical investigation was not performed.", + "Her symptoms disappeared soon after the delivery.", + "Her mother succumbed to a sudden disease.", + "The disease was characterized by acute renal and neurological injuries.", + "Further information was not available.", + "On physical examination, she was good on appearance.", + "Temperature was 38°C.", + "Blood pressure was 160/100 mmHg.", + "Pulse rate was 110 bpm.", + "Bilateral minimal pretibial edema was noticed.", + "The laboratory tests were consistent with thrombotic microangiopathy.", + "Plasma ADAMTS13 levels and activity were within the normal limits.", + "Antinuclear antibody was negative.", + "C3 level was 80 mg/dL.", + "C4 level was within the normal range.", + "Left renal agenesis was detected by urinary ultrasonography.", + "An enlarged right kidney (145 × 55 mm) was detected.", + "Genetic analysis revealed a novel mutation in exon 21 of complement factor H (CFH) (c.3454T>A; p.C1152S).", + "The same mutation was later identified in her asymptomatic 3 (males) of 4 siblings.", + "Daily plasma exchange using 40 mL/kg fresh frozen plasma was started.", + "On-demand hemodialysis was started.", + "Markers of thrombotic microangiopathy did not consistently normalize during 22 sessions of plasma exchange.", + "Plasma exchange was replaced by eculizumab within 2 weeks of vaccination against Neisseria meningitides.", + "Eculizumab was given at 900 mg/week for 4 weeks.", + "Eculizumab was given at 1200 mg every other week from the 5th week on.", + "Thrombocytopenia and elevated LDH normalized within 1 month.", + "The need for dialysis was eliminated within 2 months of eculizumab treatment.", + "Eculizumab was discontinued after 1 year of treatment.", + "The patient was set to follow-up.", + "Thrombocytes dropped and remained below the lower limit of normal from the 7th month of follow-up on.", + "LDH levels remained around the upper limit of normal.", + "Multiple peripheral blood films were found normal.", + "Serum haptoglobin levels were found normal.", + "Reticulocyte counts were found normal.", + "Levels of creatinine slightly increased but remained <2 mg/dL except for a few occasions.", + "The levels of proteinuria remained <0.5 g/day.", + "Informed consent was obtained from the patient." + ], + "summary": "One of our aHUS cases with a novel complement factor H mutation, who developed unusual laboratory findings (thrombocytopenia and mild creatinine elevation without other features of TMA) following discontinuation of eculizumab was presented. Literature and case reports relevant to discontinuation of eculizumab in aHUS patients were reviewed.", + "summary_subclaims": [ + "One of our aHUS cases had a novel complement factor H mutation.", + "The patient developed unusual laboratory findings following discontinuation of eculizumab.", + "The unusual laboratory findings included thrombocytopenia and mild creatinine elevation.", + "The unusual laboratory findings occurred without other features of TMA.", + "Literature and case reports relevant to discontinuation of eculizumab in aHUS patients were reviewed." + ] + }, + { + "id": "multiclinsum_test_1590_en.txt", + "fulltext": "A 35-year-old woman was found to have a few shadows with GGOs on chest CT in 2012. She was monitored and a shadow in right S10 was found to increase in size, which suggested lung adenocarcinoma. The patient was referred to our hospital for further evaluation. The patient had a history of bronchial asthma. The shadow in right S10 had increased to 14 × 8 mm by 2015 . Other shadows also appeared . After preoperative CT-guided marking, the patient underwent video-assisted thoracoscopic surgery with a right wedge resection of the lower lobe that included the largest nodule in S10 and other nodules. Her postoperative course was uneventful.\nGrossly, the surgical specimen contained pale, somewhat yellow lesions . Histopathological examination of the right S10 lesion and other nodules revealed small- or medium-sized lymphocyte-like cells that were located in the alveolar interseptal spaces. The alveolar walls remained intact . Immunohistochemical staining showed that tumor cells were positive for CD20 (1:400 dilution; DAKO, Carpinteria, CA, USA, Fig. ), CD79a (1:200 dilution; DAKO, Carpinteria, CA, USA), and BCL2 (1:50 dilution; DAKO, Carpinteria, CA, USA, Fig. ) expression and negative for CD10 (1:50 dilution; Novocastra, Newcastle upon Tyne, UK), cyclin D1 (1:75 dilution; DAKO, Carpinteria, CA, USA) and CD30 (1:40 dilution; DAKO, Carpinteria, CA, USA). The lesions were diagnosed as extranodal marginal zone B-cell lymphoma of MALT. The patient has remained well during 12 months of follow up after surgery. Although she did not receive chemotherapy because the MALT lymphoma lesions have been stable without progression, the patient is kept under close observation because of potential progression of the disease.", + "fulltext_subclaims": [ + "A 35-year-old woman was found to have a few shadows with GGOs on chest CT in 2012.", + "A shadow in right S10 was found to increase in size, which suggested lung adenocarcinoma.", + "The patient had a history of bronchial asthma.", + "The shadow in right S10 had increased to 14 × 8 mm by 2015.", + "Other shadows also appeared.", + "After preoperative CT-guided marking, the patient underwent video-assisted thoracoscopic surgery with a right wedge resection of the lower lobe that included the largest nodule in S10 and other nodules.", + "Her postoperative course was uneventful.", + "Grossly, the surgical specimen contained pale, somewhat yellow lesions.", + "Histopathological examination of the right S10 lesion and other nodules revealed small- or medium-sized lymphocyte-like cells that were located in the alveolar interseptal spaces.", + "The alveolar walls remained intact.", + "Immunohistochemical staining showed that tumor cells were positive for CD20 (1:400 dilution; DAKO, Carpinteria, CA, USA).", + "Immunohistochemical staining showed that tumor cells were positive for CD79a (1:200 dilution; DAKO, Carpinteria, CA, USA).", + "Immunohistochemical staining showed that tumor cells were positive for BCL2 (1:50 dilution; DAKO, Carpinteria, CA, USA).", + "Immunohistochemical staining showed that tumor cells were negative for CD10 (1:50 dilution; Novocastra, Newcastle upon Tyne, UK).", + "Immunohistochemical staining showed that tumor cells were negative for cyclin D1 (1:75 dilution; DAKO, Carpinteria, CA, USA).", + "Immunohistochemical staining showed that tumor cells were negative for CD30 (1:40 dilution; DAKO, Carpinteria, CA, USA).", + "The lesions were diagnosed as extranodal marginal zone B-cell lymphoma of MALT.", + "The patient has remained well during 12 months of follow up after surgery.", + "She did not receive chemotherapy because the MALT lymphoma lesions have been stable without progression.", + "The patient is kept under close observation because of potential progression of the disease." + ], + "summary": "A 35-year-old woman was found to have a few shadows with ground glass opacities on chest computed tomography (CT) in 2012. A shadow in right S10 that was initially very small increased in size over time, and was 14 × 8 mm in 2015. Other shadows also appeared. Because lung adenocarcinoma was suspected, the patient underwent video-assisted thoracoscopic surgery with a right wedge resection of the lower lobe that included the largest nodule in S10 and other nodules. Histopathological examination of the right S10 and other lesions revealed small- or medium-sized lymphocyte-like cells that were located in the alveolar interseptal spaces. The alveolar walls remained intact. Immunohistochemical staining showed that tumor cells were positive for CD20, CD79a, and BCL2 expression. The lesions were diagnosed as extranodal marginal zone B-cell lymphoma of MALT.", + "summary_subclaims": [ + "A 35-year-old woman was found to have a few shadows with ground glass opacities on chest computed tomography (CT) in 2012.", + "A shadow in right S10 that was initially very small increased in size over time.", + "The shadow in right S10 was 14 × 8 mm in 2015.", + "Other shadows also appeared.", + "Lung adenocarcinoma was suspected.", + "The patient underwent video-assisted thoracoscopic surgery with a right wedge resection of the lower lobe that included the largest nodule in S10 and other nodules.", + "Histopathological examination of the right S10 and other lesions revealed small- or medium-sized lymphocyte-like cells that were located in the alveolar interseptal spaces.", + "The alveolar walls remained intact.", + "Immunohistochemical staining showed that tumor cells were positive for CD20, CD79a, and BCL2 expression.", + "The lesions were diagnosed as extranodal marginal zone B-cell lymphoma of MALT." + ] + }, + { + "id": "multiclinsum_test_2141_en.txt", + "fulltext": "A one-year-old male patient presented at the cardiothoracic surgery department of South Valley University Hospital with right-sided chest swelling for 4 days duration associated with non-radiating pain. The chest swelling was gradual in onset, with a progressive course. His mother presented that he had a history of productive cough for two weeks duration. Three weeks prior, he had been hospitalized with a urinary tract infection. There were no systemic symptoms, rash, or chills. There was no history of chest trauma or previous surgery.\nOn examination, the patient appeared ill, with increased work of breathing. His temperature was 38.8 °C, heart rate was 120 beats per minute, and respiratory rate was 43 breaths per minute. Oxygen saturation was 94 % on room air. Inspection of the chest revealed a prominent, erythematous, firm, and tender swelling in the right back of the chest, measuring approximately 10 cm in diameter. The overlying skin was warm, with evidence of fluctuation without spontaneous discharge .\nA chest X-ray revealed a significant amount of right-sided pleural effusion and a wholly opaque right lung. The subsequent chest CT scan confirmed the presence of Rt lower lobe consolidation and loculated pleural effusion extending along the lateral and posterior chest wall .\nLeukocytosis (white blood cell count of 18,000 cells/mm3) was discovered by laboratory testing. To identify the causative organism, a sample of the pleural fluid was collected for microbiological analysis. Gram staining showed numerous polymorphonuclear leukocytes and gram-negative bacilli. Culture of the pleural fluid grew Escherichia coli, confirming the diagnosis of empyema necessitans due to an Escherichia coli infection. Based on the isolated strain's susceptibility patterns, we initiated the empiric antibiotic therapy with intravenous cefotaxime 200 mg/kg/day and intravenous vancomycin 60 mg/kg/day to cover the most likely pathogens, such as Streptococcus pneumoniae and Staphylococcus aureus. And Once culture and sensitivity results become available, the patient was immediately started on the appropriate intravenous antibiotics. The third-generation cephalosporin was a component of the antibiotic regimen.\nUnder general anesthesia, the patient underwent surgical drainage, the abscess loculation was broken down effectively in all directions, and yellowish-white pus was drained; thereafter, the abscess cavity was thoroughly irrigated with sterile saline solution. Moreover, the abscess cavity was packed with sterile gauze. Lastly, a thoracostomy tube was inserted to drain the pleural cavity. Then patient was admitted to ICU for close monitoring, respiratory support, and postoperative care. The child's clinical course was constantly observed, and laboratory values, vital signs, and respiratory status were evaluated on a regular basis. Throughout the hospital stay, the patient gradually displayed clinical improvement. The swelling on the right side of his chest gradually went down in size as his fever reduced, respiratory symptoms was improved. Follow-up imaging revealed that the pleural effusion had resolved, and the lung regain its expansion. After 14 days, the patient successfully finished the intravenous antibiotic regimen and was discharged in stable condition. At the 1-month follow-up, the child remained asymptomatic with no recurrence of infection .", + "fulltext_subclaims": [ + "A one-year-old male patient presented at the cardiothoracic surgery department of South Valley University Hospital.", + "The patient had right-sided chest swelling for 4 days duration.", + "The chest swelling was associated with non-radiating pain.", + "The chest swelling was gradual in onset.", + "The chest swelling had a progressive course.", + "The patient had a history of productive cough for two weeks duration.", + "Three weeks prior, the patient had been hospitalized with a urinary tract infection.", + "There was no history of chest trauma.", + "There was no history of previous surgery.", + "On examination, the patient appeared ill.", + "The patient had increased work of breathing.", + "The patient's temperature was 38.8 °C.", + "The patient's heart rate was 120 beats per minute.", + "The patient's respiratory rate was 43 breaths per minute.", + "Oxygen saturation was 94 % on room air.", + "Inspection of the chest revealed a prominent, erythematous, firm, and tender swelling in the right back of the chest.", + "The swelling measured approximately 10 cm in diameter.", + "The overlying skin was warm.", + "There was evidence of fluctuation without spontaneous discharge.", + "A chest X-ray revealed a significant amount of right-sided pleural effusion.", + "A chest X-ray showed a wholly opaque right lung.", + "A chest CT scan confirmed the presence of Rt lower lobe consolidation.", + "A chest CT scan showed loculated pleural effusion extending along the lateral and posterior chest wall.", + "Leukocytosis (white blood cell count of 18,000 cells/mm3) was discovered by laboratory testing.", + "A sample of the pleural fluid was collected for microbiological analysis.", + "Gram staining showed numerous polymorphonuclear leukocytes and gram-negative bacilli.", + "Culture of the pleural fluid grew Escherichia coli.", + "The diagnosis was empyema necessitans due to an Escherichia coli infection.", + "Empiric antibiotic therapy with intravenous cefotaxime 200 mg/kg/day and intravenous vancomycin 60 mg/kg/day was initiated.", + "The antibiotic regimen was intended to cover the most likely pathogens, such as Streptococcus pneumoniae and Staphylococcus aureus.", + "The third-generation cephalosporin was a component of the antibiotic regimen.", + "The patient underwent surgical drainage under general anesthesia.", + "The abscess loculation was broken down effectively in all directions.", + "Yellowish-white pus was drained.", + "The abscess cavity was thoroughly irrigated with sterile saline solution.", + "The abscess cavity was packed with sterile gauze.", + "A thoracostomy tube was inserted to drain the pleural cavity.", + "The patient was admitted to ICU for close monitoring, respiratory support, and postoperative care.", + "The patient gradually displayed clinical improvement.", + "The swelling on the right side of the chest gradually went down in size.", + "The patient's fever reduced.", + "The patient's respiratory symptoms improved.", + "Follow-up imaging revealed that the pleural effusion had resolved.", + "The lung regained its expansion.", + "After 14 days, the patient successfully finished the intravenous antibiotic regimen.", + "The patient was discharged in stable condition.", + "At the 1-month follow-up, the child remained asymptomatic.", + "There was no recurrence of infection." + ], + "summary": "A one-year-old boy presented with symptoms that were in line with empyema necessitans, and Escherichia coli was shown to be the causative organism. A successful outcome required early detection, rapid diagnosis, and proper management, which included targeted antibiotic medication and drainage of the pleural collection. When a young patient exhibits a growing chest wall swelling, empyema necessitans should be considered in the differential diagnosis.", + "summary_subclaims": [ + "A one-year-old boy presented with symptoms that were in line with empyema necessitans.", + "Escherichia coli was shown to be the causative organism.", + "A successful outcome required early detection.", + "A successful outcome required rapid diagnosis.", + "A successful outcome required proper management.", + "Proper management included targeted antibiotic medication.", + "Proper management included drainage of the pleural collection.", + "When a young patient exhibits a growing chest wall swelling, empyema necessitans should be considered in the differential diagnosis." + ] + }, + { + "id": "multiclinsum_test_2011_en.txt", + "fulltext": "A 16-year-old woman treated with adjuvant Nivolumab presented with vomiting, nausea, and weight loss.\nThe patient was diagnosed with stage IIIb malignant melanoma (T3bN1aM0). Both the primary melanoma and sentinel lymph node were radically removed. The patient was offered adjuvant treatment with Nivolumab (anti-PD-1), with 6 mg/kg administered every 4 wk. Initially, the patient tolerated the treatment well with only a small rise in plasma alanine transaminase compatible with a grade 1 hepatitis. An ultrasound examination of the liver was performed without any abnormalities observed.\nAfter the sixth series of Nivolumab, the patient presented with anorexia, vomiting, nausea, upper abdominal pain, and a weight loss of approximately 3 kg . The patient was admitted and received a short low-dose prednisone treatment for 4 d (40 mg methylprednisolone on the first day followed by 25 mg prednisone for 3 d) with a little initial symptomatic effect. The patient was discharged after 3 d, but readmitted 10 d later because of worsening of her symptoms with dehydration, vomiting, and stomach pain.\nThe patient had no comorbidities. There was no history of prior gastroenterological symptoms.\nThe patient did not smoke or consume alcohol. There was no noteworthy family medical history.\nPhysical examination showed a pale and dehydrated patient with a weight loss of 3 kg. The abdomen was soft but revealed tenderness in the epigastrium.\nBlood tests showed a slight elevation in alanine transaminase (91 U/L; reference range 10-45 U/L) compatible with grade 1 hepatitis. Additional blood tests, including thyrotropin and cortisol, were in normal range.\nAt first admission after the sixth Nivolumab dose, a cerebral magnetic resonance imaging was performed to rule out metastases to the brain. In the following week a positron emission tomography with computed tomography (PET-CT) was performed. Abnormal fluorodeoxyglucose uptake was demonstrated in the gastric wall, especially around the corpus antrum . Linitis plastica was suspected and an esophagogastroduodenoscopy (EGD) with supplementary endoscopic ultrasound (EUS) was performed. The EGD showed a vulnerable mucosa with a white fibrine-like membrane in the antrum, corpus, and fundus. EUS demonstrated increased thickening of the gastric wall to 13 mm. No focal malignant lesions were suspected, and the finding was interpreted as inflammation. Macroscopically, the mucosa was erythematous with severe fibrinous erosions .\nThe initial endoscopical examination was compatible with chronic active pangastritis . Biopsies from fundus, corpus, and antrum ventriculi showed severe changes with ulceration, crustation, and only scattered glands. The glandular epithelium showed very reactive changes, apoptosis, neutrophilic inflammation, and crypt abscesses, as well as intraepithelial lymphocytosis (45 per 100 epithelial cells). The lamina propria showed a diffuse, full thickness lymphoplasmacytic inflammatory infiltrate. Epithelial granulomas, thickened subepithelial collagen layer, or prominent eosinophils, were not observed. There were no signs of malignancy, CMV infection, or Helicobacter pylori. Epstein Barr virus serology showed positive Epstein Barr virus nuclear antigen IgG corresponding with a previous infection.", + "fulltext_subclaims": [ + "The patient was diagnosed with stage IIIb malignant melanoma (T3bN1aM0).", + "Both the primary melanoma and sentinel lymph node were radically removed.", + "The patient was offered adjuvant treatment with Nivolumab (anti-PD-1).", + "Nivolumab was administered at 6 mg/kg every 4 wk.", + "The patient initially tolerated the treatment well.", + "There was a small rise in plasma alanine transaminase compatible with grade 1 hepatitis.", + "An ultrasound examination of the liver was performed.", + "No abnormalities were observed on the ultrasound.", + "After the sixth series of Nivolumab, the patient presented with anorexia.", + "After the sixth series of Nivolumab, the patient presented with vomiting.", + "After the sixth series of Nivolumab, the patient presented with nausea.", + "After the sixth series of Nivolumab, the patient presented with upper abdominal pain.", + "After the sixth series of Nivolumab, the patient had a weight loss of approximately 3 kg.", + "The patient received a short low-dose prednisone treatment for 4 d.", + "The patient was discharged after 3 d.", + "The patient was readmitted 10 d later.", + "The patient had no comorbidities.", + "There was no history of prior gastroenterological symptoms.", + "The patient did not smoke.", + "The patient did not consume alcohol.", + "There was no noteworthy family medical history.", + "Physical examination showed a pale and dehydrated patient.", + "The abdomen was soft but revealed tenderness in the epigastrium.", + "Blood tests showed a slight elevation in alanine transaminase (91 U/L).", + "The alanine transaminase elevation was compatible with grade 1 hepatitis.", + "A cerebral magnetic resonance imaging was performed to rule out metastases to the brain.", + "A positron emission tomography with computed tomography (PET-CT) was performed.", + "Abnormal fluorodeoxyglucose uptake was demonstrated in the gastric wall.", + "Linitis plastica was suspected.", + "An esophagogastroduodenoscopy (EGD) with supplementary endoscopic ultrasound (EUS) was performed.", + "The EGD showed a vulnerable mucosa with a white fibrine-like membrane in the antrum, corpus, and fundus.", + "EUS demonstrated increased thickening of the gastric wall to 13 mm.", + "No focal malignant lesions were suspected.", + "The finding was interpreted as inflammation.", + "The initial endoscopical examination was compatible with chronic active pangastritis.", + "Biopsies from fundus, corpus, and antrum ventriculi showed severe changes with ulceration.", + "Biopsies showed crustation.", + "Biopsies showed only scattered glands.", + "The glandular epithelium showed very reactive changes.", + "The glandular epithelium showed apoptosis.", + "The glandular epithelium showed neutrophilic inflammation.", + "The glandular epithelium showed crypt abscesses.", + "The glandular epithelium showed intraepithelial lymphocytosis (45 per 100 epithelial cells).", + "The lamina propria showed a diffuse, full thickness lymphoplasmacytic inflammatory infiltrate.", + "Epithelial granulomas were not observed.", + "A thickened subepithelial collagen layer was not observed.", + "Prominent eosinophils were not observed.", + "There were no signs of malignancy.", + "There were no signs of CMV infection.", + "There were no signs of Helicobacter pylori.", + "Epstein Barr virus serology showed positive Epstein Barr virus nuclear antigen IgG.", + "The Epstein Barr virus nuclear antigen IgG result corresponded with a previous infection." + ], + "summary": "We describe a case of a 16-year-old woman with stage IIIb malignant melanoma treated with adjuvant monotherapy using Nivolumab. The patient developed severe gastritis after six series of Nivolumab with weight loss, nausea, and vomiting. There was no effect of intravenous steroids, but the patient´s condition resolved after administration of Infliximab.", + "summary_subclaims": [ + "The patient was a 16-year-old woman.", + "The patient had stage IIIb malignant melanoma.", + "The patient was treated with adjuvant monotherapy using Nivolumab.", + "The patient developed severe gastritis after six series of Nivolumab.", + "The patient had weight loss.", + "The patient had nausea.", + "The patient had vomiting.", + "There was no effect of intravenous steroids.", + "The patient's condition resolved after administration of Infliximab." + ] + }, + { + "id": "multiclinsum_test_2150_en.txt", + "fulltext": "We report a case of a 28 years old woman, in 33 week of her first pregnancy, who was admitted to our department for severe right flank pain, detected in right hypochondrium, associated with nausea, vomiting, and irritative bladder symptoms. Personal and familial histories were unremarkable. The patient was hemodynamically stable without hematuria, lumbar pain or other urological symptoms. Physical examination revealed no specific findings, a good general condition, an axillary temperature of 38°C, blood pressure of 120/75 mmHg and a heart rate of 78 bpm. Abdominal palpation revealed no masses. The only pathological laboratory test parameter was the hemoglobin 8,7 g/dl and hematocrit of 25,5%, that required the transfusion of two red cell concentrate units.\nAbdominal ultrasound examination revealed a mass, with mixed echogenity, without acoustic shadowing well circumscribed, expanding at the upper pole of right kidney . The mass confirmed with MRI, measuring approximately 7 × 7 × 5 cm in size with evidence of recent extensive retroperitoneal bleeding, with right perirenal and intrarenal hematoma..\nAfter a couple of hours she was developed an episode of fetal bradycardia, hypotension, and a hematocrit continued to decline, despite repeated blood transfusion, which combined with symptoms of intense lumbar pain and hematuria.\nConsidering the hemodynamic instability of the patient, emergency cesarean delivery, under general anaesthesia, was undertaken, because of foetal distress. Exploration of the retroperitoneal space after foetal extraction, confirmed the presence of a large haematoma and the renal mass., which occupied the intrarenal space . Right nephrectomy was performed, and the haemorrhaging contents was evacuated. .\nThe histological study of the resected mass revealed the presence of with admixture of mature adipose tissue, smooth muscle, and thick-walled blood vessels.\nA healthy male infant was delivered and the patient had an uneventful recovery.", + "fulltext_subclaims": [ + "The patient was a 28 years old woman.", + "She was in 33 week of her first pregnancy.", + "She was admitted for severe right flank pain.", + "The pain was detected in right hypochondrium.", + "The pain was associated with nausea.", + "The pain was associated with vomiting.", + "The pain was associated with irritative bladder symptoms.", + "Personal and familial histories were unremarkable.", + "The patient was hemodynamically stable.", + "There was no hematuria.", + "There was no lumbar pain.", + "There were no other urological symptoms.", + "Physical examination revealed no specific findings.", + "The axillary temperature was 38°C.", + "The blood pressure was 120/75 mmHg.", + "The heart rate was 78 bpm.", + "Abdominal palpation revealed no masses.", + "The only pathological laboratory test parameter was the hemoglobin 8,7 g/dl.", + "The hematocrit was 25,5%.", + "The transfusion of two red cell concentrate units was required.", + "Abdominal ultrasound revealed a mass with mixed echogenity.", + "The mass was without acoustic shadowing.", + "The mass was well circumscribed.", + "The mass expanded at the upper pole of right kidney.", + "The mass was confirmed with MRI.", + "The mass measured approximately 7 × 7 × 5 cm in size.", + "There was evidence of recent extensive retroperitoneal bleeding.", + "There was right perirenal and intrarenal hematoma.", + "After a couple of hours, she developed an episode of fetal bradycardia.", + "After a couple of hours, she developed hypotension.", + "The hematocrit continued to decline despite repeated blood transfusion.", + "She had symptoms of intense lumbar pain.", + "She had hematuria.", + "Emergency cesarean delivery was undertaken.", + "The cesarean delivery was under general anaesthesia.", + "The cesarean delivery was undertaken because of foetal distress.", + "Exploration of the retroperitoneal space after foetal extraction confirmed the presence of a large haematoma.", + "The renal mass occupied the intrarenal space.", + "Right nephrectomy was performed.", + "The haemorrhaging contents were evacuated.", + "The histological study of the resected mass revealed the presence of with admixture of mature adipose tissue.", + "The histological study revealed the presence of smooth muscle.", + "The histological study revealed the presence of thick-walled blood vessels.", + "A healthy male infant was delivered.", + "The patient had an uneventful recovery." + ], + "summary": "We report a case of a 28 years old woman, in 33 week of her first pregnancy who came to our hospital complaining of abdominal pain in the right hemiabdomen, associated with nausea and vomiting. The ultrasound and MRI (Magnetic resonance imaging) scan showed a 7 x 7 x 5 cm mass suggestive of angiomyolipoma in the right kidney, with evidence of retroperitoneal bleeding right perirenal and intrarenal haematoma. Given the size of the tumor, presence of symptoms and hemodynamic instability of the patient right nephrectomy was performed, following emergency caesarean delivery. The histological study of the resected mass revealed the presence of angiomyolipoma.", + "summary_subclaims": [ + "The patient is a 28 years old woman.", + "She is in 33 week of her first pregnancy.", + "She came to the hospital complaining of abdominal pain in the right hemiabdomen.", + "She had nausea and vomiting.", + "The ultrasound and MRI scan showed a 7 x 7 x 5 cm mass.", + "The mass was suggestive of angiomyolipoma in the right kidney.", + "There was evidence of retroperitoneal bleeding.", + "There was right perirenal and intrarenal haematoma.", + "Given the size of the tumor, presence of symptoms and hemodynamic instability of the patient, right nephrectomy was performed.", + "The right nephrectomy was performed following emergency caesarean delivery.", + "The histological study of the resected mass revealed the presence of angiomyolipoma." + ] + }, + { + "id": "multiclinsum_test_1104_en.txt", + "fulltext": "A 72-year-old woman had a mass in the right frontal region for 3 years. Due to the appearance of unsteadiness when walking, a magnetic resonance imaging (MRI) was performed 6 months previously, and she was diagnosed with frontal cranial tumor. Two months earlier, the patient experienced left hemiconvulsive seizures with impaired consciousness and was started on anticonvulsant medication. Subsequently, she was referred to our hospital for treatment. She had no neurological symptoms on examination but had mild cognitive dysfunction . Electroencephalography (EEG) revealed a tendency toward slowing of background and rhythmic delta activities in the right frontotemporal region of Fp2, F4, C4, F8, T4, and T6. Computed tomography (CT) scan showed a 10.7 × 10.0 × 5.5-cm mass from the right frontal to the parietal bone, expanding into the diploic space, and partly extending beyond the sagittal suture to the contralateral side [ and ]. Perfusion CT-indicated increased blood flow and volume [ and ]. Furthermore, the venous phase of four-dimensional CT angiography revealed that the superior sagittal sinus (SSS) was occluded due to the tumor . MRI revealed a high signal on T1-weighted imaging (T1WI) and T2-weighted imaging and signal suppression on fat-suppressed T1WI, suggesting a tumor with a fat component [-]. There was no signal change in the brain parenchyma, but it was accompanied by a midline shift . The right external carotid artery angiography revealed marked tumor staining from the right middle meningeal artery (MMA) . The tumor was fed mainly from the anterior branch of the MMA, and the other feeders were the posterior convexity branch of the MMA, deep temporal artery (DTA), and superficial temporal artery. Furthermore, the draining veins were highly dilated within the tumor and formed varices . A couple of the drainers were also delineated in the arterial phase, suggesting the presence of an AVF . The right internal carotid artery angiography revealed vascular loss at the tumor site and partial disruption of the SSS. There was no feeder from the right ICA, and there was a small amount of tumor stain from the anterior branch of the left MMA and the peripheral part of the left occipital artery. In view of the radiological findings, a provisional diagnosis of an intraosseous hemangioma was established. Since it was symptomatic and the patient and her family wanted surgical treatment, we decided to perform the surgery.\nPreoperative endovascular embolization was performed with N-butyl-2-cyanoacrylate (NBCA) and particles through feeding arteries. First, we introduced the microcatheter to the anterior branch of the right MMA and DTA and injected the NBCA diluted with contrast medium to 16.7–20.0%. Next, the MMA main trunk was also embolized with Embosphere® and fibered coils. Finally, the tumor stain was dramatically reduced after embolization . Two days after embolization, the patient underwent craniotomy. A thick DTA ran under the temporal muscle and was determined to be a feeding artery; therefore, we cut it after thorough coagulation. When the flap was inverted, the tumor was partially exposed on the bone . The tumor was fragile and easily bleeding. Many entry burr-holes were made on the surrounding normal bone to avoid cutting into the tumor. Since we found that the dura mater was firmly adherent to the inner table of the cranial tumor, the outer table of the tumor was first removed piecemeal. The diploe layer, containing a large amount of fat, bone tissue, and blood vessels, believed to be the main components of the tumor, was resected. During the operation, profuse bleeding from the inner table and dura near the SSS was encountered, and a blood transfusion was performed. The bleeding was controlled by removing the inner table and attaching dura, but a small part of the tumor near the SSS was left behind to preserve venous return [ and ]. After the resection, osmotherapy was performed to prevent cerebral edema. Cranioplasty was performed using a custom-made titanium mesh plate 1 month after the tumor resection [ and ]. After the tumor resection, E3V4M6 disturbance of consciousness and MMT4/5 left paralysis appeared transiently, but those symptoms disappeared after cranioplasty. The patient’s cognitive dysfunction also improved . MRI performed 2 years after the surgery showed no tumor recurrence, the occluded SSS was refluxed, and the midline shift had disappeared [-]. The EEG findings also improved, and although the anticonvulsant was discontinued 1 year after resection following the patient’s desire, the patient has remained seizure-free.\nHistological examination revealed that the intracranial tumor was composed of mature adipocytes with various-sized dilated vessels [ and ]. There was no fibrin thrombus formation characteristic of cutaneous or soft-tissue angiolipoma. The abnormal vessels in the tumor had varices with a mild chronic inflammatory cell infiltration in the adventitia [ and ]. Immunohistochemically, these adipocytes were negative for MDM2 and p16. Taken together with the lack of cytological atypia of adipocytes and vessels , there were no findings suggestive of malignancy; thus, the patient was finally diagnosed with angiolipoma.", + "fulltext_subclaims": [ + "The patient was a 72-year-old woman.", + "She had a mass in the right frontal region for 3 years.", + "She was diagnosed with frontal cranial tumor.", + "She experienced left hemiconvulsive seizures with impaired consciousness.", + "She was started on anticonvulsant medication.", + "She was referred to the hospital for treatment.", + "She had mild cognitive dysfunction.", + "EEG revealed a tendency toward slowing of background and rhythmic delta activities in the right frontotemporal region.", + "CT scan showed a 10.7 × 10.0 × 5.5-cm mass from the right frontal to the parietal bone.", + "Perfusion CT indicated increased blood flow and volume.", + "The venous phase of four-dimensional CT angiography revealed that the superior sagittal sinus was occluded due to the tumor.", + "MRI revealed a high signal on T1-weighted imaging.", + "MRI revealed a high signal on T2-weighted imaging.", + "MRI showed signal suppression on fat-suppressed T1WI.", + "MRI findings suggested a tumor with a fat component.", + "There was no signal change in the brain parenchyma.", + "There was a midline shift.", + "Right external carotid artery angiography revealed marked tumor staining from the right middle meningeal artery.", + "The tumor was fed mainly from the anterior branch of the middle meningeal artery.", + "The draining veins were highly dilated within the tumor and formed varices.", + "A couple of the drainers were also delineated in the arterial phase, suggesting the presence of an AVF.", + "Right internal carotid artery angiography revealed vascular loss at the tumor site.", + "There was partial disruption of the superior sagittal sinus.", + "There was no feeder from the right internal carotid artery.", + "There was a small amount of tumor stain from the anterior branch of the left middle meningeal artery.", + "A provisional diagnosis of an intraosseous hemangioma was established.", + "The patient and her family wanted surgical treatment.", + "Preoperative endovascular embolization was performed with N-butyl-2-cyanoacrylate and particles.", + "The microcatheter was introduced to the anterior branch of the right middle meningeal artery.", + "The tumor stain was dramatically reduced after embolization.", + "The patient underwent craniotomy.", + "The tumor was fragile and easily bleeding.", + "The outer table of the tumor was first removed piecemeal.", + "The diploe layer, containing a large amount of fat, bone tissue, and blood vessels, was resected.", + "Profuse bleeding from the inner table and dura near the SSS was encountered.", + "A blood transfusion was performed.", + "A small part of the tumor near the SSS was left behind.", + "Cranioplasty was performed using a custom-made titanium mesh plate.", + "E3V4M6 disturbance of consciousness and MMT4/5 left paralysis appeared transiently.", + "Those symptoms disappeared after cranioplasty.", + "The patient’s cognitive dysfunction also improved.", + "MRI performed 2 years after the surgery showed no tumor recurrence.", + "The occluded superior sagittal sinus was refluxed.", + "The midline shift had disappeared.", + "The EEG findings also improved.", + "The anticonvulsant was discontinued 1 year after resection.", + "The patient has remained seizure-free.", + "Histological examination revealed that the intracranial tumor was composed of mature adipocytes with various-sized dilated vessels.", + "There was no fibrin thrombus formation characteristic of cutaneous or soft-tissue angiolipoma.", + "The abnormal vessels in the tumor had varices with a mild chronic inflammatory cell infiltration in the adventitia.", + "The adipocytes were negative for MDM2 and p16.", + "There were no findings suggestive of malignancy.", + "The patient was finally diagnosed with angiolipoma." + ], + "summary": "We reported the case of a 72-year-old woman who presented with head swelling, seizures, and cognitive dysfunction. Computed tomography and magnetic resonance imaging revealed a right frontal bone tumor exceeding a sagittal suture of up to 10.7 cm. Angiography revealed AVF and varices formation. Endovascular embolization was performed to treat the AVF and reduce blood loss during surgical resection. Two days after the embolization, a craniotomy was performed; however, uncontrollable bleeding was observed at the time of tumor resection. Postoperatively, the patient was symptom-free and has been stable for 2 years without recurrence.", + "summary_subclaims": [ + "The patient was a 72-year-old woman.", + "The patient presented with head swelling.", + "The patient presented with seizures.", + "The patient presented with cognitive dysfunction.", + "Computed tomography and magnetic resonance imaging revealed a right frontal bone tumor exceeding a sagittal suture of up to 10.7 cm.", + "Angiography revealed AVF.", + "Angiography revealed varices formation.", + "Endovascular embolization was performed to treat the AVF.", + "Endovascular embolization was performed to reduce blood loss during surgical resection.", + "Two days after the embolization, a craniotomy was performed.", + "Uncontrollable bleeding was observed at the time of tumor resection.", + "Postoperatively, the patient was symptom-free.", + "The patient has been stable for 2 years without recurrence." + ] + }, + { + "id": "multiclinsum_test_1473_en.txt", + "fulltext": "We present a 30-year-old male with selective anti-polysaccharide antibody deficiency (SPAD) and peripheral blood CD5+/CD19+ B-cell predominance (97%, control 52.5 ± 17.3%) diagnosed at 5 years old. His past medical history was significant for persistent childhood sinopulmonary infections, severe hemorrhagic varicella at 2 years old, ulcerative colitis in early adolescence, and ongoing autoimmune hepatitis. His initial immunological evaluation revealed seronegativity of 12 Streptococcus pneumoniae subtypes, Neisseria meningitidis A and C, Haemophilus influenza b, human parainfluenza viruses 1 to 3, influenza A and B, poliovirus 1 to 3, and respiratory syncytial virus. Post-vaccination antibody titers demonstrated negative pneumococcal valent conjugate serology but clinically adequate (≥.01 IU/mL) response to protein antigens tetanus and diphtheria anti-toxoids. Other immune laboratory assessments included persistently stable hypogammaglobulinemia. Blood leukocytes and mitogen- and antigen-induced lymphocyte proliferation panel were within normal limits. Serologic evidence of human immunodeficiency virus, EBV, and cytomegalovirus was absent. Immunological re-evaluation at 28 years old confirmed CD5 + B-cell predominance and revealed a MAGT1 mutation (c.923-1_934del) and reduced CD16 + CD56 + natural killer- and/or CD8 + T-cell receptor, Group 2, Member D (NKG2D) expression consistent with the XMEN genotype and phenotype.\nThe patient presented for a routine office visit with no acute symptoms. He denied recent history of COVID-19. COVID-19 vaccination and associated serology antibody testing was recommended. Anti-SARS-CoV-2 immunoglobulin (Ig)M and IgG antibodies before and after the first BNT162b2 (Pfizer/BioNTech) mRNA COVID-19 vaccine doses, as well as nucleocapsid antibody, were negative . S protein total antibody was reactive after the second dose.", + "fulltext_subclaims": [ + "The patient is a 30-year-old male.", + "The patient has selective anti-polysaccharide antibody deficiency (SPAD).", + "The patient has peripheral blood CD5+/CD19+ B-cell predominance (97%).", + "The control range for CD5+/CD19+ B-cell predominance is 52.5 ± 17.3%.", + "The patient was diagnosed with SPAD at 5 years old.", + "The patient had persistent childhood sinopulmonary infections.", + "The patient had severe hemorrhagic varicella at 2 years old.", + "The patient had ulcerative colitis in early adolescence.", + "The patient has ongoing autoimmune hepatitis.", + "The initial immunological evaluation revealed seronegativity of 12 Streptococcus pneumoniae subtypes.", + "The initial immunological evaluation revealed seronegativity to Neisseria meningitidis A and C.", + "The initial immunological evaluation revealed seronegativity to Haemophilus influenza b.", + "The initial immunological evaluation revealed seronegativity to human parainfluenza viruses 1 to 3.", + "The initial immunological evaluation revealed seronegativity to influenza A and B.", + "The initial immunological evaluation revealed seronegativity to poliovirus 1 to 3.", + "The initial immunological evaluation revealed seronegativity to respiratory syncytial virus.", + "Post-vaccination antibody titers demonstrated negative pneumococcal valent conjugate serology.", + "Post-vaccination antibody titers demonstrated clinically adequate response to tetanus and diphtheria anti-toxoids.", + "The clinically adequate response to tetanus and diphtheria anti-toxoids was defined as ≥.01 IU/mL.", + "Other immune laboratory assessments included persistently stable hypogammaglobulinemia.", + "Blood leukocytes were within normal limits.", + "Mitogen- and antigen-induced lymphocyte proliferation panel was within normal limits.", + "Serologic evidence of human immunodeficiency virus was absent.", + "Serologic evidence of EBV was absent.", + "Serologic evidence of cytomegalovirus was absent.", + "Immunological re-evaluation at 28 years old confirmed CD5 + B-cell predominance.", + "Immunological re-evaluation at 28 years old revealed a MAGT1 mutation (c.923-1_934del).", + "Immunological re-evaluation at 28 years old revealed reduced CD16 + CD56 + natural killer- and/or CD8 + T-cell receptor, Group 2, Member D (NKG2D) expression.", + "The reduced CD16 + CD56 + natural killer- and/or CD8 + T-cell receptor, Group 2, Member D (NKG2D) expression was consistent with the XMEN genotype and phenotype.", + "The patient presented for a routine office visit.", + "The patient had no acute symptoms.", + "The patient denied recent history of COVID-19.", + "The patient received the BNT162b2 (Pfizer/BioNTech) mRNA COVID-19 vaccine.", + "Anti-SARS-CoV-2 immunoglobulin (Ig)M antibodies before the first vaccine dose were negative.", + "Anti-SARS-CoV-2 immunoglobulin (Ig)G antibodies before the first vaccine dose were negative.", + "Nucleocapsid antibody before the first vaccine dose was negative.", + "Anti-SARS-CoV-2 immunoglobulin (Ig)M antibodies after the first vaccine dose were negative.", + "Anti-SARS-CoV-2 immunoglobulin (Ig)G antibodies after the first vaccine dose were negative.", + "Nucleocapsid antibody after the first vaccine dose was negative.", + "S protein total antibody was reactive after the second vaccine dose." + ], + "summary": "We present a 30-year-old male with selective anti-polysaccharide antibody deficiency, peripheral blood CD5  +  /CD19  +  B-cell predominance (97%), MAGT1 mutation, and reduced CD16  +  CD56  +  natural killer- and/or CD8  +  T-cell receptor, Group 2, Member D expression. His initial immunological evaluation revealed all seronegative post-vaccination antibody titers but clinically adequate response to protein antigens tetanus and diphtheria anti-toxoids.COVID-19 vaccination and associated serology antibody testing was recommended at this office visit. Anti-SARS-CoV-2 immunoglobulin (Ig)M and IgG antibodies before and after the first BNT162b2 mRNA COVID-19 vaccine doses, as well as nucleocapsid antibody, were negative. S protein total antibody was reactive after the second dose.", + "summary_subclaims": [ + "The patient is a 30-year-old male.", + "The patient has selective anti-polysaccharide antibody deficiency.", + "The patient has peripheral blood CD5  +  /CD19  +  B-cell predominance (97%).", + "The patient has a MAGT1 mutation.", + "The patient has reduced CD16  +  CD56  +  natural killer- and/or CD8  +  T-cell receptor, Group 2, Member D expression.", + "The patient's initial immunological evaluation revealed all seronegative post-vaccination antibody titers.", + "The patient had a clinically adequate response to protein antigens tetanus and diphtheria anti-toxoids.", + "The patient received a recommendation for COVID-19 vaccination and associated serology antibody testing at this office visit.", + "Anti-SARS-CoV-2 immunoglobulin (Ig)M antibodies before the first BNT162b2 mRNA COVID-19 vaccine dose were negative.", + "Anti-SARS-CoV-2 IgG antibodies before the first BNT162b2 mRNA COVID-19 vaccine dose were negative.", + "Nucleocapsid antibody before the first BNT162b2 mRNA COVID-19 vaccine dose was negative.", + "Anti-SARS-CoV-2 IgM antibodies after the first BNT162b2 mRNA COVID-19 vaccine dose were negative.", + "Anti-SARS-CoV-2 IgG antibodies after the first BNT162b2 mRNA COVID-19 vaccine dose were negative.", + "Nucleocapsid antibody after the first BNT162b2 mRNA COVID-19 vaccine dose was negative.", + "S protein total antibody was reactive after the second BNT162b2 mRNA COVID-19 vaccine dose." + ] + }, + { + "id": "multiclinsum_test_1082_en.txt", + "fulltext": "A 64-year-old woman was admitted to hospital because of dehiscence of a sternal wound, after a mitral valve replacement that was performed 2 months earlier due to severe insufficiency. She presented a clinical history of rheumatic mitral stenosis, which was treated with closed mitral valvulotomy 35 years previously, resulting in a mitral insufficiency. Twenty-three years previously she had suffered a bacterial endocarditis due to viridans group streptococci that led to cerebral embolism.\nOn examination, a white material was found to be exuded from the sternal wound when pressed over the wound margins. A computed tomography scan of the chest showed a dehiscence of the surgical wound, with swelling of soft tissue above the sternum and osteitis of the sternal bone. Apart from a C-reactive protein level of 2.6 mg dl−1 and an albumin level of 3.1 g dl−1, laboratory studies were unremarkable.\nEmpirical treatment with clindamycin (300 mg/6h i.v.) and ceftazidime (2 g/8h i.v.) was started. The treatment was changed to imipenem (500 mg/6h i.v.) and ciprofloxacin (750 mg/12h p.o.) after a preliminary microbiology laboratory report of growth of an actinomycete with presumed susceptibility to several antimicrobials. Surgical debridement of the wound was performed. This treatment was maintained for 3 weeks, but successive wound cultures continued showing the presence of the actinomycete organism. Because the symptoms did not improve, sternal cerclage was removed and antibiotic therapy was shifted to teicoplanin (400 mg/24h i.v.) plus ciprofloxacin (750 mg/12h p.o.) and rifampin (600 mg/24h p.o.) for 2 weeks, followed by ciprofloxacin plus rifampin for an additional6 weeks, resulting in wound healing.\nCulture of wound samples on chocolate and blood agar plates for 72 h at 37 °C in aerobic conditions yielded creamy-white, dry, wrinkled and non-haemolytic colonies. After these 3 days, a colour change was observed in the colonies from white to yellowish. Colony appearance showed synnemata and no aerial hyphae (see ). Gram staining yielded Gram-positive short coryneform rods without branching. Modified Ziehl–Neelsen staining confirmed slight acid-fastness. Both conventional Ziehl–Neelsen and auramine stains were negative. The micro-organism was non-spore-forming, and catalase and urease positive. Casein, hypoxanthine, tyrosine and gelatine were not decomposed. Arylsulfatase production was negative within 3 days. Nitrate was not reduced to nitrite and indole was not produced. With the API NH strip (bioMérieux) acid was produced from glucose, fructose and sucrose. 16S rRNA gene sequence analysis using the blast algorithm showed 99.9 % similarity to G. bronchialis strain DSM 43247 (GenBank accession no. ).\nAn antimicrobial-susceptibility assay was performed using Etest strips (bioMérieux) on Mueller–Hinton agar with 5 % defibrinated horse blood and 20 mg β-NAD l−1 (MH-F; Oxoid). Readings were taken after 48 h of incubation, and susceptibility categories were defined according to Clinical and Laboratory Standards Institute (CLSI) guidelines for mycobacteria, nocardiae and other actinomycetes . The isolate was resistant to clindamycin (MIC=8 mg l−1), and susceptible to amoxicillin/clavulanic (0.016 mg l−1), ceftriaxone (0.5 mg l−1), imipenem (0.008 mg l−1), ciprofloxacin (0.06 mg l−1), amikacin (0.06 mg l−1), tobramycin (0.12 mg l−1), clarithromycin (2 mg l−1), minocycline (0.25 mg l−1), linezolid (1 mg l−1) and co-trimoxazole (0.03 mg l−1). Although no susceptibility breakpoints have been established for vancomycin and teicoplanin by the CLSI, MIC values were low (0.25 and 1 mg l−1, respectively).\nThe isolate was analysed by two MALDI-TOF MS-based systems, a Bruker Biotyper (Bruker Daltonics) and a Vitek MS (bioMérieux). Identification of G. bronchialis (99.9 % identity) was obtained with the Vitek MS (saramis 3.0 software) following the procedure recommended by the manufacturer. Briefly, target slides were inoculated into the spots by picking a freshly grown overnight colony and overlaid with 1 µl matrix solution, α-cyano-4-hydroxycinnamic acid. The same result was attained with the Bruker Biotyper (version 3.1 software), using a complete protocol of protein extraction with formic acid and acetonitrile, following the Bruker Biotyper instructions, but the score value (1.72) was lower than the one defined in the manufacturer’s criteria (≥2.00) for acceptance of identification at the species level.", + "fulltext_subclaims": [ + "The patient was a 64-year-old woman.", + "She was admitted to hospital because of dehiscence of a sternal wound.", + "The mitral valve replacement was performed 2 months earlier.", + "The mitral valve replacement was due to severe insufficiency.", + "She had a clinical history of rheumatic mitral stenosis.", + "The rheumatic mitral stenosis was treated with closed mitral valvulotomy 35 years previously.", + "The closed mitral valvulotomy resulted in mitral insufficiency.", + "She had suffered bacterial endocarditis 23 years previously.", + "The bacterial endocarditis was due to viridans group streptococci.", + "The bacterial endocarditis led to cerebral embolism.", + "A white material was found to be exuded from the sternal wound when pressed over the wound margins.", + "A computed tomography scan showed a dehiscence of the surgical wound.", + "The computed tomography scan showed swelling of soft tissue above the sternum.", + "The computed tomography scan showed osteitis of the sternal bone.", + "The C-reactive protein level was 2.6 mg dl−1.", + "The albumin level was 3.1 g dl−1.", + "Empirical treatment with clindamycin (300 mg/6h i.v.) and ceftazidime (2 g/8h i.v.) was started.", + "The treatment was changed to imipenem (500 mg/6h i.v.) and ciprofloxacin (750 mg/12h p.o.).", + "The change in treatment was based on a preliminary microbiology report of growth of an actinomycete.", + "The actinomycete was presumed to be susceptible to several antimicrobials.", + "Surgical debridement of the wound was performed.", + "The treatment was maintained for 3 weeks.", + "Successive wound cultures continued showing the presence of the actinomycete organism.", + "Because the symptoms did not improve, sternal cerclage was removed.", + "Antibiotic therapy was shifted to teicoplanin (400 mg/24h i.v.) plus ciprofloxacin (750 mg/12h p.o.) and rifampin (600 mg/24h p.o.).", + "This treatment was continued for 2 weeks.", + "Antibiotic therapy was then shifted to ciprofloxacin plus rifampin for an additional 6 weeks.", + "This treatment resulted in wound healing.", + "Culture of wound samples on chocolate and blood agar plates for 72 h at 37 °C in aerobic conditions yielded creamy-white, dry, wrinkled and non-haemolytic colonies.", + "After 3 days, a colour change was observed in the colonies from white to yellowish.", + "Colony appearance showed synnemata and no aerial hyphae.", + "Gram staining yielded Gram-positive short coryneform rods without branching.", + "Modified Ziehl–Neelsen staining confirmed slight acid-fastness.", + "Both conventional Ziehl–Neelsen and auramine stains were negative.", + "The micro-organism was non-spore-forming.", + "The micro-organism was catalase and urease positive.", + "Casein, hypoxanthine, tyrosine and gelatine were not decomposed.", + "Arylsulfatase production was negative within 3 days.", + "Nitrate was not reduced to nitrite.", + "Indole was not produced.", + "With the API NH strip, acid was produced from glucose, fructose and sucrose.", + "16S rRNA gene sequence analysis showed 99.9 % similarity to G. bronchialis strain DSM 43247.", + "The isolate was resistant to clindamycin (MIC=8 mg l−1).", + "The isolate was susceptible to amoxicillin/clavulanic (0.016 mg l−1).", + "The isolate was susceptible to ceftriaxone (0.5 mg l−1).", + "The isolate was susceptible to imipenem (0.008 mg l−1).", + "The isolate was susceptible to ciprofloxacin (0.06 mg l−1).", + "The isolate was susceptible to amikacin (0.06 mg l−1).", + "The isolate was susceptible to tobramycin (0.12 mg l−1).", + "The isolate was susceptible to clarithromycin (2 mg l−1).", + "The isolate was susceptible to minocycline (0.25 mg l−1).", + "The isolate was susceptible to linezolid (1 mg l−1).", + "The isolate was susceptible to co-trimoxazole (0.03 mg l−1).", + "The isolate was analysed by two MALDI-TOF MS-based systems.", + "Identification of G. bronchialis (99.9 % identity) was obtained with the Vitek MS.", + "The same result was attained with the Bruker Biotyper.", + "The score value with the Bruker Biotyper was 1.72." + ], + "summary": "Here, we present a new clinical case of persistent wound infection caused by Gordonia bronchialis in a 64-year-old woman after a mitral valve replacement, using two MALDI-TOF-based systems for identifying this micro-organism.", + "summary_subclaims": [ + "A 64-year-old woman had a mitral valve replacement.", + "She developed a persistent wound infection.", + "The infection was caused by Gordonia bronchialis.", + "Two MALDI-TOF-based systems were used for identifying the micro-organism." + ] + }, + { + "id": "multiclinsum_test_2376_en.txt", + "fulltext": "A 61-year-old woman without any risk factor of arteriosclerosis visited a nearby hospital because of mild head injury. Magnetic resonance (MR) imaging demonstrated no apparent traumatic lesion. However, flow-void sign of the right middle cerebral artery was sluggish . Cerebrovascular disease was suspected and she was referred to our hospital for further examination. She was neurologically intact and had no significant history of weakness or sensory disturbance. Moreover, her family has not experienced cerebrovascular disease. Right carotid angiogram demonstrated stenosis of the terminal portion of the ICA with moyamoya vessels . Left carotid angiogram and left vertebral angiogram showed no apparent abnormality [Figure and ]. Single photon emission computed tomography (SPECT) demonstrated hypoperfusion in the right cerebral hemisphere. The response to the acetazolamide was impaired . She was diagnosed as unilateral MMD and followed by MR imaging annually. During 6 years, she had been intact and MR imaging had not detected progression of MMD. However, 7 years after the diagnosis, cerebral aneurysm appeared in the right basal cistern, probably from anterior choroidal artery, and conventional angiography was planed . Before that, she become comatose and brought to our hospital emergently. Computed tomography (CT) showed massive intraventricular hemorrhage . Enlargement of the aneurysm was revealed by CT angiography [Figure –]. Intracerebral hematoma was evacuated and the aneurysm was obliterated by bipolar coagulation. Postoperatively, she was in vegetative state and transferred to the rehabilitation hospital.", + "fulltext_subclaims": [ + "The patient is a 61-year-old woman.", + "The patient had no risk factor of arteriosclerosis.", + "The patient visited a nearby hospital because of mild head injury.", + "MR imaging demonstrated no apparent traumatic lesion.", + "Flow-void sign of the right middle cerebral artery was sluggish.", + "Cerebrovascular disease was suspected.", + "She was referred to our hospital for further examination.", + "She was neurologically intact.", + "She had no significant history of weakness.", + "She had no significant history of sensory disturbance.", + "Her family has not experienced cerebrovascular disease.", + "Right carotid angiogram demonstrated stenosis of the terminal portion of the ICA with moyamoya vessels.", + "Left carotid angiogram showed no apparent abnormality.", + "Left vertebral angiogram showed no apparent abnormality.", + "SPECT demonstrated hypoperfusion in the right cerebral hemisphere.", + "The response to the acetazolamide was impaired.", + "She was diagnosed as unilateral MMD.", + "She was followed by MR imaging annually.", + "During 6 years, she had been intact.", + "MR imaging had not detected progression of MMD.", + "7 years after the diagnosis, cerebral aneurysm appeared in the right basal cistern.", + "The cerebral aneurysm was probably from anterior choroidal artery.", + "Conventional angiography was planned.", + "She became comatose.", + "She was brought to our hospital emergently.", + "CT showed massive intraventricular hemorrhage.", + "Enlargement of the aneurysm was revealed by CT angiography.", + "Intracerebral hematoma was evacuated.", + "The aneurysm was obliterated by bipolar coagulation.", + "Postoperatively, she was in vegetative state.", + "She was transferred to the rehabilitation hospital." + ], + "summary": "A 61-year-old woman was diagnosed as unilateral MMD incidentally and followed by magnetic resonance imaging annually. Seven years after the diagnosis, cerebral aneurysm appeared on the moyamoya vessel. Before further examination, the aneurysm ruptured and resulted in massive cerebral hemorrhage.", + "summary_subclaims": [ + "A 61-year-old woman was diagnosed as unilateral MMD incidentally.", + "She was followed by magnetic resonance imaging annually.", + "Seven years after the diagnosis, cerebral aneurysm appeared on the moyamoya vessel.", + "Before further examination, the aneurysm ruptured.", + "The aneurysm rupture resulted in massive cerebral hemorrhage." + ] + }, + { + "id": "multiclinsum_test_155_en.txt", + "fulltext": "A 59-year-old man was admitted to Coronary Care Unit because of suspected ST-segment-elevation myocardial infarction. The patient was complaining of typical coronary chest pain during the last twelve hours. He had a history of dyslipidemia, type 2 diabetes mellitus, smoking habit and a transient ischemic attack without any sensitive or motor squele one year ago. On admission, his blood pressure was 100/60 and heart rate was 110 beats per minute. Cardiac examination revealed jugular vein distension, and no significant heart murmurs. The ECG showed significant Q waves in II, III and aVf leads with mild ST-segment elevation in leads II, III, aVf and V4R. The chest radiograph revealed no cardiomegaly and clear lung fields. Transthoracic echocardiography was performed showing akinetic inferoseptal, inferior, and inferolateral segments with estimated left ventricular ejection fraction of 45%, right ventricle showed a global hipokinesia with severe systolic dysfunction and inferior vena cava plethora. The patient was initially treated with aspirin, low-molecular-weight heparin, dobutamine and saline infusions, and was scheduled for early catheterization. Coronary angiography showed total occlusion of right coronary artery proximal segment and two additional 70% stenoses in the first diagonal and obtuse marginal branches. Percutaneous revascularization was dismissed after a failed attempt of right coronary artery opening, then, the patient was treated using conservative medical therapy (aspirin 100 mg/day, clopidogrel 75 mg/day, simvastatin 20 mg/day and enalapril 10 mg/day), anticoagulation was maintained for 72 hours, and beta blocker therapy was not started because Mobitz I atrioventricular block phases were detected in continuous ECG monitoring. The later clinical outcome in the Coronary Care Unit was favourable, and the patient was discharged six days after to cardiology hospitalization unit. Nine days after hospital admission, the patient complained about sudden chest pain and rest dyspnea, his blood pressure was 80/40 and cardiac examination revealed a new harsh, holosystolic murmur along the left sternal border. Transthoracic echocardiography was immediately performed showing complex ventricular septal defect with a dissection tract that originated on left side of the basal inferoseptal akinetic segments, extended beyond the septum dissecting the right ventricular wall, and subsequently re-entered into the right ventricle chamber . No significant right ventricle outflow tract obstruction was present. The patient was scheduled for immediate surgical intervention, and hypothermic cardiopulmonary bypass with myocardial protection was established in the following two hours. The septal rupture was approached through the infarct, and prosthetic material (Gore-Tex® patch) was used to reconstruct the septum, additionally, two bypasses using vein grafts were done in first diagonal and posterior descending arteries. Postoperative evolution was favourable with rapid resolution of cardiogenic shock situation. One month later transesophageal echocardiography was performed showing neither right ventricle dissecting tract or residual shunt. Left ventricular ejection fraction was 55%, and right ventricular systolic function was only mildly depressed. At six-month follow-up the patient remains stable and without any cardiac symptoms.", + "fulltext_subclaims": [ + "A 59-year-old man was admitted to Coronary Care Unit because of suspected ST-segment-elevation myocardial infarction.", + "The patient was complaining of typical coronary chest pain during the last twelve hours.", + "He had a history of dyslipidemia.", + "He had a history of type 2 diabetes mellitus.", + "He had a history of smoking habit.", + "He had a history of a transient ischemic attack without any sensitive or motor squele one year ago.", + "On admission, his blood pressure was 100/60.", + "On admission, his heart rate was 110 beats per minute.", + "Cardiac examination revealed jugular vein distension.", + "The ECG showed significant Q waves in II, III and aVf leads.", + "The ECG showed mild ST-segment elevation in leads II, III, aVf and V4R.", + "Transthoracic echocardiography was performed.", + "Transthoracic echocardiography showed akinetic inferoseptal, inferior, and inferolateral segments.", + "Transthoracic echocardiography showed estimated left ventricular ejection fraction of 45%.", + "Transthoracic echocardiography showed right ventricle global hipokinesia with severe systolic dysfunction.", + "Transthoracic echocardiography showed inferior vena cava plethora.", + "The patient was initially treated with aspirin.", + "The patient was initially treated with low-molecular-weight heparin.", + "The patient was initially treated with dobutamine.", + "The patient was initially treated with saline infusions.", + "The patient was scheduled for early catheterization.", + "Coronary angiography showed total occlusion of right coronary artery proximal segment.", + "Coronary angiography showed two additional 70% stenoses in the first diagonal and obtuse marginal branches.", + "Percutaneous revascularization was dismissed after a failed attempt of right coronary artery opening.", + "The patient was treated using conservative medical therapy.", + "Anticoagulation was maintained for 72 hours.", + "Beta blocker therapy was not started because Mobitz I atrioventricular block phases were detected in continuous ECG monitoring.", + "The later clinical outcome in the Coronary Care Unit was favourable.", + "The patient was discharged six days after to cardiology hospitalization unit.", + "Nine days after hospital admission, the patient complained about sudden chest pain.", + "Nine days after hospital admission, the patient complained about rest dyspnea.", + "Transthoracic echocardiography was immediately performed.", + "Transthoracic echocardiography showed complex ventricular septal defect with a dissection tract that originated on left side of the basal inferoseptal akinetic segments.", + "Transthoracic echocardiography showed the dissection tract extended beyond the septum dissecting the right ventricular wall.", + "Transthoracic echocardiography showed the dissection tract subsequently re-entered into the right ventricle chamber.", + "The patient was scheduled for immediate surgical intervention.", + "Hypothermic cardiopulmonary bypass with myocardial protection was established in the following two hours.", + "The septal rupture was approached through the infarct.", + "Prosthetic material (Gore-Tex® patch) was used to reconstruct the septum.", + "Two bypasses using vein grafts were done in first diagonal and posterior descending arteries.", + "Postoperative evolution was favourable.", + "One month later transesophageal echocardiography was performed.", + "Transesophageal echocardiography showed neither right ventricle dissecting tract or residual shunt.", + "Left ventricular ejection fraction was 55%.", + "Right ventricular systolic function was only mildly depressed.", + "At six-month follow-up the patient remains stable.", + "At six-month follow-up the patient remains without any cardiac symptoms." + ], + "summary": "We present a case of a 59-year-old man who had a septal rupture with right ventricular wall dissection after inferior and right ventricular myocardial infarction. Transthoracic echocardiography, as first line examination, established the diagnosis, and prompt surgical repair allowed long-term survival in our patient.", + "summary_subclaims": [ + "The patient was a 59-year-old man.", + "The patient had a septal rupture.", + "The patient had right ventricular wall dissection.", + "The septal rupture and right ventricular wall dissection occurred after inferior and right ventricular myocardial infarction.", + "Transthoracic echocardiography was used as the first line examination.", + "Transthoracic echocardiography established the diagnosis.", + "Prompt surgical repair allowed long-term survival in the patient." + ] + }, + { + "id": "multiclinsum_test_120_en.txt", + "fulltext": "A 52-year-old man was admitted in our institutional emergency department for chest pain, sweating, and vomiting. The patient had no medical history or known cardiovascular risk factors and denied any other symptoms. Blood pressure was 85/50 mmHg and heart rate 54 b.p.m. Intravenous fluid administration was started to manage hypotension. Twelve-lead electrocardiogram showed sinus rhythm with only non-specific ST-segment changes . Trans-thoracic echocardiogram showed normal global and regional left and right ventricular function and normal size of left and right chambers. In particular, left ventricular ejection fraction was 60%, left ventricular end-diastolic diameter was 45 mm, and right ventricular end-diastolic diameter was 38 mm. Troponin T levels were mildly elevated (3.0 and 5.0 ng/L at 0 and 3 h, respectively).\nThe clinical presentation was consistent with non-ST-segment elevation acute coronary syndrome (ACS). Aspirin was administered and patient underwent coronary angiography, which revealed a patent large left anterior descending coronary artery providing collaterals to a large dominant right coronary artery draining into the pulmonary artery . Non-obstructive coronary artery disease was found. Right and left cardiac catheterization was concomitantly performed, showing a normal pulmonary artery pressure (24/10 mmHg, average 12 mmHg) and a non-significant left-to-right shunt (pulmonary venous oxygen saturation 95%; pulmonary artery oxygen saturation 80%; mixed venous oxygen saturation 76%; QP/QS: 1.3). Then, the patient was transferred to our Cardiac Care Unit for monitoring.\nAfter 2 days, a cardiac computed tomography (CT) angiography was performed to better define the coronary anatomy. CT angiography confirmed ARCAPA, excluded any other coronary anomalies and showed normal calibre of pulmonary arterial vessels (diameter of pulmonary trunk: 26 mm; ). Finally, a 99mTechnetium-gated single-photon emission computerized tomography (SPECT) with bicycle exercise test and then a 201Thallium-gated SPECT with dipyridamole were performed to assess the functional implication of the coronary anomaly , showing a reversible mild inferior perfusion defect without any significant difference between the two tests. Stress test was maximal: it lasted 9 min and the patient attained 154 b.p.m. (91% of target heart rate), 6.8 estimated metabolic equivalents and 180/85 mmHg as peak blood pressure. The patient experiences a subsequent event-free hospital stay, and was discharged on aspirin 100 mg and bisoprolol 2.5 mg. The patient was educated on actions to prevent future vaso-vagal episodes, including keeping adequate fluid intake (2 L/day), recognizing prodromes and lying down and performing counter manoeuvres in case of vaso-vagal symptoms. Also, in order to minimize gastrointestinal triggers the patient was visited by a gastroenterologist and diet recommendations were made.\nAt 2-year follow up, the patient was asymptomatic and repeated myocardial scintigraphy with dipyridamole stress test was performed after beta-blocker washout. The test confirmed the reversible mild inferior perfusion defect, previously observed. Bisoprolol dosage was up-titrated to 3.75 mg daily and aspirin was maintained.", + "fulltext_subclaims": [ + "A 52-year-old man was admitted in our institutional emergency department for chest pain, sweating, and vomiting.", + "The patient had no medical history or known cardiovascular risk factors.", + "Blood pressure was 85/50 mmHg.", + "Heart rate was 54 b.p.m.", + "Intravenous fluid administration was started to manage hypotension.", + "Twelve-lead electrocardiogram showed sinus rhythm with only non-specific ST-segment changes.", + "Trans-thoracic echocardiogram showed normal global and regional left and right ventricular function.", + "Trans-thoracic echocardiogram showed normal size of left and right chambers.", + "Left ventricular ejection fraction was 60%.", + "Left ventricular end-diastolic diameter was 45 mm.", + "Right ventricular end-diastolic diameter was 38 mm.", + "Troponin T levels were 3.0 ng/L at 0 h.", + "Troponin T levels were 5.0 ng/L at 3 h.", + "The clinical presentation was consistent with non-ST-segment elevation acute coronary syndrome.", + "Aspirin was administered.", + "Coronary angiography revealed a patent large left anterior descending coronary artery providing collaterals to a large dominant right coronary artery draining into the pulmonary artery.", + "Non-obstructive coronary artery disease was found.", + "Right and left cardiac catheterization showed a normal pulmonary artery pressure of 24/10 mmHg.", + "Right and left cardiac catheterization showed a non-significant left-to-right shunt.", + "The patient was transferred to our Cardiac Care Unit for monitoring.", + "A cardiac computed tomography angiography was performed.", + "CT angiography confirmed ARCAPA.", + "CT angiography excluded any other coronary anomalies.", + "CT angiography showed normal calibre of pulmonary arterial vessels.", + "A 99mTechnetium-gated SPECT with bicycle exercise test was performed.", + "A 201Thallium-gated SPECT with dipyridamole was performed.", + "The tests showed a reversible mild inferior perfusion defect.", + "Stress test was maximal.", + "The patient was discharged on aspirin 100 mg and bisoprolol 2.5 mg.", + "The patient was educated on actions to prevent future vaso-vagal episodes.", + "The patient was visited by a gastroenterologist and diet recommendations were made.", + "At 2-year follow up, the patient was asymptomatic.", + "Repeated myocardial scintigraphy with dipyridamole stress test was performed after beta-blocker washout.", + "The test confirmed the reversible mild inferior perfusion defect.", + "Bisoprolol dosage was up-titrated to 3.75 mg daily." + ], + "summary": "We describe the case of a 52-year-old male patient with undiagnosed ARCAPA, who acceded to our emergency department with suspected acute myocardial infarction and was discharged with medical therapy after demonstration of mild ischaemia at myocardial perfusion imaging with dipyridamole and bicycle exercise test.", + "summary_subclaims": [ + "The patient is a 52-year-old male.", + "The patient had undiagnosed ARCAPA.", + "The patient acceded to the emergency department with suspected acute myocardial infarction.", + "The patient was discharged with medical therapy.", + "Mild ischaemia was demonstrated at myocardial perfusion imaging with dipyridamole and bicycle exercise test." + ] + }, + { + "id": "multiclinsum_test_1409_en.txt", + "fulltext": "A 62-year-old woman with MMS in the left eye of few month duration underwent a complete ophthalmologic examination that included best-corrected visual acuity (BCVA), slit-lamp biomicroscopy, fundus examination, and applanation tonometry. Spectral domain optic coherence tomography (SD-OCT) images were obtained with Cirrus HD-OCT (Carl Zeiss AG, Oberkochen, Germany) at baseline and at all follow-up visits (one, four, and seven months). Subfoveal macular thickness was 706 micrometers (µm), vision was 20/200, and PPV was scheduled. The patient had a history of phacoemulsification in the left eye.\nThe anesthetists performed sedation and a retrobulbar block. The NGENUITYⓇ digitally assisted vitreoretinal surgery system (Alcon, Inc., Fort Worth, TX) was connected to replace the oculars of the microscope. The 3-D high definition real-time video was displayed on the NGENUITYⓇ4K 3-D flat-panel placed at 1.3 m from the surgeon. To be able to see in 3-D, the surgeon wore polarized glasses. Traditional vitreoretinal techniques, with the Constellation Vision System (Alcon, Inc, Fort Worth, TX), were performed without obstacles, including core vitrectomy, posterior hyaloid detachment, and peripheral vitrectomy. Brilliant blue G (DORC, Zuidland, the Netherlands) was used to stain the ILM and the surgeon performed fs-ILM peeling using disposable 25-gauge end-grasping forceps under I-OCT [Figure 2]. The I-OCT also proved that there were no iatrogenic lesions , so it was decided not to perform gas tamponade. The subfoveal macular thickness improved from 706 µm (preoperative), 540 µm (after one month), 214 µm (after four months) to 221 µm (after seven months) [Figure 3] and the visual acuity improved to 20/40 after seven months of follow-up.", + "fulltext_subclaims": [ + "The patient is a 62-year-old woman.", + "The patient had MMS in the left eye.", + "The MMS had been present for several months.", + "A complete ophthalmologic examination was performed.", + "The examination included best-corrected visual acuity.", + "The examination included slit-lamp biomicroscopy.", + "The examination included fundus examination.", + "The examination included applanation tonometry.", + "Spectral domain optic coherence tomography images were obtained with Cirrus HD-OCT.", + "SD-OCT images were obtained at baseline.", + "SD-OCT images were obtained at one month.", + "SD-OCT images were obtained at four months.", + "SD-OCT images were obtained at seven months.", + "Subfoveal macular thickness was 706 micrometers.", + "Vision was 20/200.", + "PPV was scheduled.", + "The patient had a history of phacoemulsification in the left eye.", + "The anesthetists performed sedation.", + "A retrobulbar block was performed.", + "The NGENUITYⓇ digitally assisted vitreoretinal surgery system was connected.", + "The NGENUITYⓇ4K 3-D flat-panel was placed at 1.3 m from the surgeon.", + "The surgeon wore polarized glasses.", + "Traditional vitreoretinal techniques were performed.", + "The techniques included core vitrectomy.", + "The techniques included posterior hyaloid detachment.", + "The techniques included peripheral vitrectomy.", + "Brilliant blue G was used to stain the ILM.", + "The surgeon performed fs-ILM peeling using disposable 25-gauge end-grasping forceps.", + "The I-OCT showed no iatrogenic lesions.", + "It was decided not to perform gas tamponade.", + "Subfoveal macular thickness improved from 706 µm preoperatively.", + "Subfoveal macular thickness was 540 µm after one month.", + "Subfoveal macular thickness was 214 µm after four months.", + "Subfoveal macular thickness was 221 µm after seven months.", + "Visual acuity improved to 20/40 after seven months of follow-up." + ], + "summary": "A 62-year-old woman with vision loss in the left eye was scheduled for pars plana vitrectomy (PPV) and MMS repair. Surgery was performed using the NGENUITYⓇ system for surgical viewing, and foveal-sparing internal limiting membrane (fs-ILM) peeling was performed without gas tamponade, after confirming the absence of iatrogenic macular hole with I-OCT. There were no intraoperative or postoperative complications. Visual acuity improved to 20/40 and the subfoveal macular thickness improved from 706 µm (preoperative) to 221 µm after seven months of follow-up.", + "summary_subclaims": [ + "The patient was a 62-year-old woman.", + "The patient had vision loss in the left eye.", + "The patient was scheduled for pars plana vitrectomy and MMS repair.", + "The NGENUITYⓇ system was used for surgical viewing.", + "Foveal-sparing internal limiting membrane peeling was performed.", + "Gas tamponade was not used.", + "I-OCT was used to confirm the absence of iatrogenic macular hole.", + "There were no intraoperative complications.", + "There were no postoperative complications.", + "Visual acuity improved to 20/40.", + "Subfoveal macular thickness improved from 706 µm preoperatively to 221 µm after seven months." + ] + }, + { + "id": "multiclinsum_test_2440_en.txt", + "fulltext": "A 62-year-old woman with type-2 diabetes mellitus and high blood pressure came to the emergency department with nine days of malaise, high-grade fever, cough, and progressive dyspnea, which led to acute respiratory failure that required invasive mechanical ventilation. A polymerase chain reaction for the SARS-CoV-2 virus was positive. Chest radiography showed bilateral ground-glass opacities and alveolar infiltrates. Biochemical analyses showed leukocytosis (13 000 cells/mm3) with neutrophilia (11 900 cells/mm3), lymphopenia (510 cells/mm3), and an elevated hs-C reactive protein (5 mg/dl), with preserved renal and liver function. She was started on IV dexamethasone and transferred to the intensive care unit.\nOn the third day, the patient had a sudden hemodynamic collapse with hypotension, tachycardia, and increased blood lactate levels, requiring vasopressor support. An electrocardiogram showed ST-segment elevation in the precordial leads with diffuse T-wave inversion . Transthoracic echocardiography showed severe left ventricular (LV) systolic dysfunction, with regional wall motion abnormalities characterized by extensive mid and apical dyskinesia with preserved mobility in the basal segments (Supplementary Video). Hs-Troponin I was measured and found to be 8000 ng/L (reference value: 14 ng/L). An emergency coronary angiography was performed to rule out an acute ST-elevation myocardial infarction. We documented normal flow in all coronary arteries and no relevant obstructions.\nLeft ventriculography showed diffuse apical dyskinesia with basal segment hyperkinesia and apical ballooning, consistent with an apical variant of Takotsubo syndrome (TTS) (Supplementary Video).\nShe was started on levosimendan and her hemodynamic parameters and clinical status improved, which allowed us to withdraw vasopressors. We continued the management of severe COVID-19 pneumonia with respiratory support. Echocardiography showed normal wall motion in all territories and recovery of LV function on day seven (Supplementary Video). The patient had a good clinical evolution, was weaned from respiratory support, and was discharged with complete recovery after one month of hospitalization.", + "fulltext_subclaims": [ + "The patient is a 62-year-old woman.", + "She has type-2 diabetes mellitus.", + "She has high blood pressure.", + "She had nine days of malaise.", + "She had high-grade fever.", + "She had cough.", + "She had progressive dyspnea.", + "She had acute respiratory failure.", + "She required invasive mechanical ventilation.", + "A polymerase chain reaction for the SARS-CoV-2 virus was positive.", + "Chest radiography showed bilateral ground-glass opacities.", + "Chest radiography showed alveolar infiltrates.", + "Biochemical analyses showed leukocytosis (13 000 cells/mm3).", + "Biochemical analyses showed neutrophilia (11 900 cells/mm3).", + "Biochemical analyses showed lymphopenia (510 cells/mm3).", + "Biochemical analyses showed an elevated hs-C reactive protein (5 mg/dl).", + "She was started on IV dexamethasone.", + "She was transferred to the intensive care unit.", + "On the third day, the patient had a sudden hemodynamic collapse.", + "An electrocardiogram showed ST-segment elevation in the precordial leads.", + "An electrocardiogram showed diffuse T-wave inversion.", + "Transthoracic echocardiography showed severe left ventricular (LV) systolic dysfunction.", + "Transthoracic echocardiography showed regional wall motion abnormalities.", + "Hs-Troponin I was 8000 ng/L.", + "An emergency coronary angiography was performed.", + "Coronary angiography showed normal flow in all coronary arteries.", + "Coronary angiography showed no relevant obstructions.", + "Left ventriculography showed diffuse apical dyskinesia.", + "Left ventriculography showed apical ballooning.", + "The findings were consistent with an apical variant of Takotsubo syndrome.", + "She was started on levosimendan.", + "Her hemodynamic parameters improved.", + "She was weaned from vasopressors.", + "Echocardiography showed normal wall motion in all territories.", + "Echocardiography showed recovery of LV function on day seven.", + "The patient was weaned from respiratory support.", + "The patient was discharged after one month of hospitalization.", + "The patient had complete recovery." + ], + "summary": "It can have a diverse clinical presentation, occasionally resembling an acute coronary syndrome, and progress to acute heart failure and cardiogenic shock, adversely affecting patients' prognosis. A high index of suspicion and a thorough diagnostic approach supported by ancillary studies like echocardiography and coronary angiography is key for an accurate diagnosis and correct medical treatment. Herein, we report a patient with severe COVID-19 who developed Takotsubo cardiomyopathy.", + "summary_subclaims": [ + "It can have a diverse clinical presentation.", + "It can occasionally resemble an acute coronary syndrome.", + "It can progress to acute heart failure and cardiogenic shock.", + "A high index of suspicion is key for an accurate diagnosis.", + "A thorough diagnostic approach is key for an accurate diagnosis.", + "Ancillary studies like echocardiography and coronary angiography are key for an accurate diagnosis.", + "Ancillary studies like echocardiography and coronary angiography are key for correct medical treatment.", + "We report a patient with severe COVID-19 who developed Takotsubo cardiomyopathy." + ] + }, + { + "id": "multiclinsum_test_976_en.txt", + "fulltext": "A 69-year-old Hispanic male with no documented past medical history presented to the emergency department with a 3-week history of shortness of breath, intermittent chest pain, and lower extremity edema. Initial vital signs were notable for an elevated blood pressure of 150/86 mmHg and a heart rate of 73 bpm. Jugular venous distention was markedly elevated to 12 cm of water (cm H2O), alongside sparse bibasilar crackles on pulmonary exam and 1 + pitting pedal oedema. Brain natriuretic peptide was as high as 881 pg/mL [reference range (RR): 0–100 pg/mL] with a high sensitivity troponin I of 16 ng/L [RR: 0–20 ng/L], which peaked to 18 ng/L 2 h later. Chest radiograph revealed trace pulmonary vascular congestion and cardiomegaly. Electrocardiogram demonstrated sinus rhythm with non-specific T-wave abnormalities . Transthoracic echocardiogram (TTE) demonstrated a left ventricular systolic ejection fraction (EF) of 68%. Left ventricular diastolic function was found to include an E/A ratio of 2.91, E/e′ ratio of 11.15, and deceleration time of 151 msec. Additional findings included a dilated left and right atrium with severe tricuspid regurgitation (TR), moderate mitral regurgitation (MR), malcoaptation of the tricuspid valve leaflets, and a myxomatous mitral valve (, , ). There was a moderately enlarged right ventricle with moderately reduced systolic function and evidence of pulmonary hypertension (see , ). The patient was subsequently hospitalized for newly diagnosed acute decompensated right heart failure with preserved left ventricular EF.\nTwo days after the initiation of aggressive diuresis with intravenous furosemide, a right heart catheterization demonstrated mildly elevated right heart pressures (mean right atrial 8 mmHg, right ventricle 31/8 mmHg, pulmonary artery 31/12 mmHg, and pulmonary capillary wedge pressure of 10 mmHg). A coronary angiogram revealed normal coronary arteries. The aetiology of this patient’s heart failure remained unclear. Given the significant valvular abnormalities, thyroid studies were sent for further workup. Thyroid-stimulating hormone (TSH) was significantly low at <0.010 uIU/mL (RR: 0.45–4.12 uIU/mL), along with an elevated free T4 of 1.96 ng/dL (RR: 0.60–1.12 ng/dL).\nSubsequent serological data revealed slightly elevated thyroid peroxidase antibody of 11 IU/mL [RR: <9 IU/mL], negative thyroid-stimulating immunoglobulin (TSI index <1.0), and negative thyroglobulin antibody (<1 IU/mL). Thyroid ultrasound showed a 4.9 cm lesion in the left thyroid lobe . The patient’s thyrotoxicosis was believed to likely be attributed to toxic adenoma. It was determined that the patient’s heart failure and valve abnormalities were likely consistent with thyrotoxic heart disease. Methimazole 10 mg once daily was initiated for treatment in addition to furosemide for diuresis and carvedilol and losartan for hypertension. The patient was discharged to a shelter, but unfortunately, he was lost to follow-up and did not obtain a TTE after completion of treatment due to social circumstances.", + "fulltext_subclaims": [ + "The patient is a 69-year-old Hispanic male.", + "The patient had no documented past medical history.", + "The patient presented with a 3-week history of shortness of breath.", + "The patient had intermittent chest pain.", + "The patient had lower extremity edema.", + "Initial blood pressure was 150/86 mmHg.", + "Jugular venous distention was 12 cm of water.", + "Brain natriuretic peptide was 881 pg/mL.", + "High sensitivity troponin I was 16 ng/L.", + "Chest radiograph showed trace pulmonary vascular congestion.", + "Transthoracic echocardiogram demonstrated a left ventricular systolic ejection fraction of 68%.", + "The E/e′ ratio was 11.15.", + "The patient had severe tricuspid regurgitation.", + "The patient had a moderately enlarged right ventricle.", + "The patient was hospitalized for newly diagnosed acute decompensated right heart failure.", + "Right heart catheterization showed a mean right atrial pressure of 8 mmHg.", + "Thyroid-stimulating hormone was <0.010 uIU/mL.", + "Free T4 was 1.96 ng/dL.", + "Thyroid peroxidase antibody was 11 IU/mL.", + "Thyroid-stimulating immunoglobulin was negative.", + "Thyroid ultrasound showed a 4.9 cm lesion in the left thyroid lobe.", + "The patient’s thyrotoxicosis was believed to be attributed to toxic adenoma.", + "The patient’s heart failure and valve abnormalities were likely consistent with thyrotoxic heart disease.", + "Methimazole 10 mg once daily was initiated.", + "The patient was discharged to a shelter.", + "The patient was lost to follow-up." + ], + "summary": "A 69-year-old Hispanic male presented with a 3-week history of shortness of breath, intermittent chest pain, and lower extremity swelling. Transthoracic echocardiogram revealed a dilated left and right atrium with severe tricuspid regurgitation, moderate mitral regurgitation, malcoaptation of the tricuspid valve leaflets, and a myxomatous mitral valve. In addition, right ventricular systolic function was moderately reduced. A right and left heart catheterization was performed with findings of normal right heart pressures and normal coronary arteries, respectively. To further evaluate the aetiology of the patient's heart failure, thyroid studies were sent, revealing a thyroid-stimulating hormone value of <0.010 uIU/mL and a free T4 of 1.96 ng/dL. A 4.9 cm lesion was seen on thyroid ultrasound. We concluded that the patient's heart failure and notable valvular abnormalities were likely as a result of thyrotoxic heart disease. Furosemide and methimazole were initiated while inpatient, and the patient was discharged with close follow-up.", + "summary_subclaims": [ + "The patient is a 69-year-old Hispanic male.", + "The patient had a 3-week history of shortness of breath.", + "The patient had intermittent chest pain.", + "The patient had lower extremity swelling.", + "Transthoracic echocardiogram revealed a dilated left and right atrium.", + "Transthoracic echocardiogram showed severe tricuspid regurgitation.", + "Transthoracic echocardiogram showed moderate mitral regurgitation.", + "Transthoracic echocardiogram showed malcoaptation of the tricuspid valve leaflets.", + "Transthoracic echocardiogram showed a myxomatous mitral valve.", + "Right ventricular systolic function was moderately reduced.", + "Right heart catheterization showed normal right heart pressures.", + "Left heart catheterization showed normal coronary arteries.", + "Thyroid-stimulating hormone was <0.010 uIU/mL.", + "Free T4 was 1.96 ng/dL.", + "A 4.9 cm lesion was seen on thyroid ultrasound.", + "The patient's heart failure and notable valvular abnormalities were likely as a result of thyrotoxic heart disease.", + "Furosemide was initiated while inpatient.", + "Methimazole was initiated while inpatient." + ] + }, + { + "id": "multiclinsum_test_876_en.txt", + "fulltext": "A 60- year-old Aboriginal female, presented to our emergency department following collapse at home. She was on Warfarin for paroxysmal atrial fibrillation and mitral regurgitation and her past medical history included hypertension, hypercholesterolemia, depression and cerebro vascular accident without any residual effect.\nOn presentation, she was agitated; her heart rate was 96/minute and systolic blood pressure was 70 mm of mercury. Clinical examination showed a distended abdomen with generalized tenderness. Laboratory investigation revealed Haemoglobin of 48 g/L, White blood count of 19.3 × 10/L and International Normalised Ratio (INR) of 1.7. Venous blood gases showed PH of 7.3, and a lactate of 6.03.\nShe was resuscitated with intravenous fluids, red blood cells and fresh frozen plasma. She had a cardiac arrest during resuscitation and Cardio Pulmonary Resuscitation was performed with good outcome. An urgent laparotomy was performed for apparent intra- abdominal bleeding.\nLaparotomy showed 3 litres of free intraperitoneal blood and a large haematoma involving the lesser curve, upper body of stomach and the gastro oesophageal junction. The haematoma was expanding with active bleeding from the left gastric artery and its branches. Local measures to control the bleeding in this unstable patient failed and a total gastrectomy had to be performed.\nDamage control principles were applied due to hemodynamic instability and reconstruction deferred with stapling of her oesophageal stump. An abdominal vacuum assisted closure (VAC™) dressing was applied and she was transferred to the Intensive care unit, where she was stabilised and her coagulopathy corrected.\nA Roux-en-Y oesophago- jejunal anastomosis with Hunt - Lawrence pouch reconstruction and a feeding jejunostomy was undertaken thirty six hours later. Five days later, a gastrograffin swallow demonstrated anastomotic integrity; she was commenced on a diet and discharged 14 days after admission.\nHistological evaluation of the gastrectomy specimen and extensive sampling of the vessels revealed the diagnostic clues. Figures A, B and show SAM in the reparative phase with significant segmental disruption of the media by pronounced fibromyxoid proliferation and marked expansion of the intima in the moderate-sized arteries, with granulation tissue filling gaps and extending over the intima of arterial wall islands. In other areas of the arteries, there is often marked attenuation of media with gap formation only prevented by retained internal elastic and intima . The lesions showed only scanty inflammation characterized by some occasional sparse lymphocytes and collection of haemosiderin containing histiocytes . Focally, there was abrupt disruption of media with recoil of the internal elastic lamina, fibromyxoid tissue herniation into the adventitia and microaneurysmal appearances . Occasional small arteries showed intimal thickening, internal elastic lamina fragmentation, and attenuation of media. There was no evident feature of fibrosis and scarring.\nFollow-up Computerised Tomography (CT) Mesenteric Angiogram scan 3 months later showed no significant vascular structure abnormality. Twelve months later, the patient remains asymptomatic.", + "fulltext_subclaims": [ + "The patient was a 60-year-old Aboriginal female.", + "She presented to the emergency department following collapse at home.", + "She was on Warfarin for paroxysmal atrial fibrillation.", + "She had a past medical history of hypertension.", + "She had a past medical history of hypercholesterolemia.", + "She had a past medical history of depression.", + "She had a past medical history of cerebrovascular accident without any residual effect.", + "On presentation, her systolic blood pressure was 70 mm of mercury.", + "Clinical examination showed a distended abdomen with generalized tenderness.", + "Laboratory investigation revealed Haemoglobin of 48 g/L.", + "Venous blood gases showed a lactate of 6.03.", + "She was resuscitated with intravenous fluids.", + "She had a cardiac arrest during resuscitation.", + "Cardio Pulmonary Resuscitation was performed with good outcome.", + "An urgent laparotomy was performed for apparent intra-abdominal bleeding.", + "Laparotomy showed 3 litres of free intraperitoneal blood.", + "The haematoma was expanding with active bleeding from the left gastric artery and its branches.", + "Local measures to control the bleeding in this unstable patient failed.", + "A total gastrectomy had to be performed.", + "An abdominal vacuum assisted closure (VAC™) dressing was applied.", + "She was transferred to the Intensive care unit.", + "A Roux-en-Y oesophago-jejunal anastomosis with Hunt-Lawrence pouch reconstruction was undertaken thirty six hours later.", + "Five days later, a gastrograffin swallow demonstrated anastomotic integrity.", + "She was discharged 14 days after admission.", + "Histological evaluation of the gastrectomy specimen revealed the diagnostic clues.", + "The lesions showed only scanty inflammation characterized by some occasional sparse lymphocytes and collection of haemosiderin containing histiocytes.", + "There was no evident feature of fibrosis and scarring.", + "Follow-up Computerised Tomography (CT) Mesenteric Angiogram scan 3 months later showed no significant vascular structure abnormality.", + "Twelve months later, the patient remains asymptomatic." + ], + "summary": "A 60 years old Aboriginal female presented with life threatening, spontaneous intra-abdominal bleeding requiring an emergency laparotomy. The source of bleeding was found to be ruptured left gastric artery. A total gastrectomy was performed as a damage control procedure. A staged Roux-en-Y oesophago-jejunostomy with Hunt Lawrence pouch reconstruction was undertaken thirty six hours later. Histopathological findings revealed evidence of non-inflammatory segmental vascular damage with microaneurysm, consistent with segmental arterial mediolysis.", + "summary_subclaims": [ + "The patient is a 60 years old Aboriginal female.", + "The patient had life threatening, spontaneous intra-abdominal bleeding.", + "The bleeding required an emergency laparotomy.", + "The source of bleeding was found to be ruptured left gastric artery.", + "A total gastrectomy was performed as a damage control procedure.", + "A staged Roux-en-Y oesophago-jejunostomy with Hunt Lawrence pouch reconstruction was undertaken thirty six hours later.", + "Histopathological findings revealed evidence of non-inflammatory segmental vascular damage with microaneurysm.", + "The histopathological findings were consistent with segmental arterial mediolysis." + ] + }, + { + "id": "multiclinsum_test_532_en.txt", + "fulltext": "Our patient is a 48-year-old female who has a history of localized early stage right renal cell carcinoma and had undergone an open right radical nephrectomy in 2002 via a right flank incision. She is in remission currently.\nDuring her surveillance, an MRI done in August 2010 detected an incidental lesion in her spleen measuring 3.9 cm. A follow up MRI done 3 months later showed the lesion to have increased in size to 4.5 cm. Interventional radiology performed a CT guided biopsy and the pathology showed it to be a possible spindle cell tumor or an inflammatory myofibroblastic tumor. A PET CT done showed low level activity in the splenic lesion. She denied any other local or constitutional symptoms.\nShe had previously undergone a left oophorectomy and salphingectomy for an ectopic pregnancy, both via a Pfannenstiel incision. She has 3 children, all vaginal delivery.\nDue to her menorrhagia for the past couple of months, an ultrasound of her pelvis was done which showed large uterine fibroids. She was scheduled for a laparoscopic hysterectomy in 3 weeks.\nPhysical examination was unremarkable except for her previous Pfannenstiel and right flank incisions.\nDue to the indeterminate nature of her splenic lesion with concerns for malignancy, patient was agreeable to undergoing a splenectomy. Discussion with her gynecologist then yielded the possibility doing both surgeries on the same day, possibly doing the laparoscopic splenectomy first, then the laparoscopic hysterectomy. After a careful review of the literature, we also pursued the idea of transvaginally extracting the spleen after the hysterectomy was performed. Pneumococcal and Hib vaccines were given 2 weeks prior to surgery.\nShe underwent surgery in February 2011. Pre-operatively, the left ureter was stented to protect the left ureter in view of her single remaining kidney. The laparoscopic splenectomy was conducted with the patient in the supine position. One 12 mm port and 3 other 5 mm ports were placed in a diamond configuration in the left upper quadrant.\nThe splenectomy was performed with standard laparoscopic dissection techniques. Hem-O-Lok clips (Weck Closure Systems, Research Triangle Park, NC) were applied to the splenic vessels. No complications were encountered.\nThe remaining attachments were taken down and the spleen was passed into a 15 mm Endo Catch bag (Covidien, Dublin, Ireland). The splenic hilum was hemostatic and the bag containing the spleen was parked above the liver. The case was then turned over to the gynecologist for the hysterectomy.\nThe vagina was cleansed and a Rumi II (Cooper Surgical Inc®, Trumbull, CT) uterine manipulator was introduced. The left lateral umbilical, sub-xiphoid and left anterior axillary line ports were reused for placement of the robotic instrument trocars. Laparoscopic transvaginal hysterectomy was performed in the standard fashion with no complications. The right adnexae were conserved. The colpotomy incision was extended till complete and the uterus was flipped forwards and amputated. The uterus was then removed via an Endo Catch bag placed through the vagina and a septal bulb on a sponge stick was placed to tent up the vaginal cuff to maintain pneumoperitoneum .\nTotal operative time was 245 min and estimated blood loss was 50 mls.\nPatient had an uneventful post-operative course and was discharged home on post-operative day 2.\nPathology showed a benign fibrous lesion in the spleen measuring 4.7 cm × 4.0 cm × 3.1 cm and this was called to represent either a sclerotic splenic hamartoma or a burned out inflammatory pseudotumor. The spleen weighed 175gms and measured 10.5 cm × 7.8 cm × 5.1 cm. The uterus weighed 210 gm with multifocal adenomyosis as well as intramural leiomyoma.\nHer first post-operative clinic visit was in March and she was doing well, back to her regular physical activities. Abdominal incisions were well healed. She resumed sexual activity at 6 weeks post procedure and noted no dyspareunia or any abnormal change in sensation. She was seen in June where she noted an episode of post-coital bleeding. Physical exam revealed some raw granulation tissue at the colpotomy incision site which was managed with topical creams and postponement of sexual activity for 2 weeks. Since then, no recurrence of her vaginal bleeding was noted after resumption of coitus. To date, she remains well with no symptoms related to her surgery.", + "fulltext_subclaims": [ + "The patient is a 48-year-old female.", + "She has a history of localized early stage right renal cell carcinoma.", + "She had undergone an open right radical nephrectomy in 2002 via a right flank incision.", + "She is currently in remission.", + "An MRI done in August 2010 detected an incidental lesion in her spleen measuring 3.9 cm.", + "A follow up MRI done 3 months later showed the lesion to have increased in size to 4.5 cm.", + "Interventional radiology performed a CT guided biopsy.", + "The pathology showed it to be a possible spindle cell tumor or an inflammatory myofibroblastic tumor.", + "A PET CT showed low level activity in the splenic lesion.", + "She denied any other local or constitutional symptoms.", + "She had previously undergone a left oophorectomy and salphingectomy for an ectopic pregnancy.", + "Both procedures were via a Pfannenstiel incision.", + "She has 3 children, all vaginal delivery.", + "An ultrasound of her pelvis showed large uterine fibroids.", + "She was scheduled for a laparoscopic hysterectomy in 3 weeks.", + "Physical examination was unremarkable except for her previous Pfannenstiel and right flank incisions.", + "Due to the indeterminate nature of her splenic lesion with concerns for malignancy, patient was agreeable to undergoing a splenectomy.", + "Discussion with her gynecologist yielded the possibility of doing both surgeries on the same day.", + "The idea of transvaginally extracting the spleen after the hysterectomy was pursued.", + "Pneumococcal and Hib vaccines were given 2 weeks prior to surgery.", + "She underwent surgery in February 2011.", + "The left ureter was stented pre-operatively to protect the left ureter.", + "The laparoscopic splenectomy was conducted with the patient in the supine position.", + "One 12 mm port and 3 other 5 mm ports were placed in a diamond configuration in the left upper quadrant.", + "The splenectomy was performed with standard laparoscopic dissection techniques.", + "Hem-O-Lok clips were applied to the splenic vessels.", + "No complications were encountered.", + "The spleen was passed into a 15 mm Endo Catch bag.", + "The splenic hilum was hemostatic.", + "The bag containing the spleen was parked above the liver.", + "The gynecologist then performed the hysterectomy.", + "The vagina was cleansed and a Rumi II uterine manipulator was introduced.", + "The left lateral umbilical, sub-xiphoid and left anterior axillary line ports were reused.", + "Laparoscopic transvaginal hysterectomy was performed in the standard fashion with no complications.", + "The right adnexae were conserved.", + "The colpotomy incision was extended till complete and the uterus was flipped forwards and amputated.", + "The uterus was removed via an Endo Catch bag placed through the vagina.", + "A septal bulb on a sponge stick was placed to tent up the vaginal cuff.", + "Total operative time was 245 min.", + "Estimated blood loss was 50 mls.", + "The patient was discharged home on post-operative day 2.", + "Pathology showed a benign fibrous lesion in the spleen measuring 4.7 cm × 4.0 cm × 3.1 cm.", + "The lesion was called to represent either a sclerotic splenic hamartoma or a burned out inflammatory pseudotumor.", + "The spleen weighed 175gms and measured 10.5 cm × 7.8 cm × 5.1 cm.", + "The uterus weighed 210 gm with multifocal adenomyosis as well as intramural leiomyoma.", + "Her first post-operative clinic visit was in March.", + "She was doing well, back to her regular physical activities.", + "Abdominal incisions were well healed.", + "She resumed sexual activity at 6 weeks post procedure.", + "She noted no dyspareunia or any abnormal change in sensation.", + "She was seen in June where she noted an episode of post-coital bleeding.", + "Physical exam revealed some raw granulation tissue at the colpotomy incision site.", + "The granulation tissue was managed with topical creams.", + "Sexual activity was postponed for 2 weeks.", + "No recurrence of her vaginal bleeding was noted after resumption of coitus.", + "She remains well with no symptoms related to her surgery." + ], + "summary": "Patient underwent laparoscopic splenectomy and robot-assisted hysterectomy with transvaginal delivery of specimens. Total operative time was 245min with no complications. Closure of the colpotomy was achieved laparoscopically. Post-operative course was unremarkable. Patient has done well clinically at 18 months follow-up except for an episode of post-coital spotting, which resolved spontaneously.", + "summary_subclaims": [ + "Patient underwent laparoscopic splenectomy.", + "Patient underwent robot-assisted hysterectomy.", + "Specimens were delivered transvaginally.", + "Total operative time was 245min.", + "There were no complications.", + "Closure of the colpotomy was achieved laparoscopically.", + "Post-operative course was unremarkable.", + "The patient has done well clinically at 18 months follow-up.", + "The patient had an episode of post-coital spotting.", + "The episode of post-coital spotting resolved spontaneously." + ] + }, + { + "id": "multiclinsum_test_1716_en.txt", + "fulltext": "In April 2023, a 39-year-old Chinese woman presented to our hospital complaining of a black shadow in front of her right eye for 5 days. This patient had been diagnosed with acute lymphoblastic leukaemia in 2017 and received an autologous HSCT in 2018. Unfortunately, she suffered a relapse of leukaemia and underwent an allogeneic HSCT in October 2022. The patient developed ocular symptoms at 6 months after receiving the transplant. After the consultation, the patient received a series of tests including visual acuity, slit lamp, noncontact tonometer, ocular ultrasound, macular optical coherence tomography, and Optos fundus photography. The patient’s best corrected visual acuity was 20/20 in both eyes using the Snellen visual acuity chart. The intraocular pressure was within the normal range. Slit lamp examination revealed that the anterior segmental structures of both eyes were normal. Ultrasound of the eye suggested flocculent vitreous clouding in the lower part of the right eye . Partial signal enhancement in the retina of the left eye was found, and part of the photoreceptor cell layer was missing on optical coherence tomography(OCT) . Fundus photography revealed a yellowish-white exudate with haemorrhage in the peripheral retina of the right eye and a faint haemorrhage in the lower retina of the left eye . Combining the medical history and relevant ophthalmic examination, we highly suspected that the patient had developed cytomegalovirus retinitis.\nTherefore, we performed anterior atrial puncture and extracted aqueous humour from the patient for viral testing on 23, April. We further refined FFA + ICGA on April 25. Surprisingly, utilizing broad-spectrum high-throughput sequencing, it was found that the aqueous humour of her right eye tested positive for three viral DNAs-CMV, EBV, and HSV . Internal markings and no template control were added to rule out a false detection of both herpes viruses during the high-throughput sequencing. The left eye was positive for CMV only. The FFA + ICGA findings indicated a small amount of retinal exudate in the patient’s right eye, and a large area of obscured fluorescence in the subnasal and inferior choroid . The patient was then treated with bilateral vitreous cavity ganciclovir injections. Viral DNA was retested one week later and no virus was detected in the aqueous humour of either eye by quantitative polymerase chain reaction(QPCR). The test was negative for viral DNA. OCT and fundus photography indicated no significant changes in the fundus. The patients underwent weekly serum cytomegalovirus and EBV testing after the second stem cell transplant. She was cytomegalovirus positive only between November 15, 2022 and January 14, 2023, with viral copy numbers ranging from 1.02 × 102 to 2.37 × 104 during this period. Each test was negative for EBV. The patient was treated with systemic antiviral therapy in the hematology department since February, 2023. As of May 22, 2023, her fundal lesions all remained stable.", + "fulltext_subclaims": [ + "A 39-year-old Chinese woman presented to the hospital in April 2023 with a black shadow in front of her right eye for 5 days.", + "The patient had been diagnosed with acute lymphoblastic leukaemia in 2017.", + "She received an autologous HSCT in 2018.", + "She suffered a relapse of leukaemia and underwent an allogeneic HSCT in October 2022.", + "The patient developed ocular symptoms at 6 months after receiving the allogeneic transplant.", + "The patient’s best corrected visual acuity was 20/20 in both eyes using the Snellen visual acuity chart.", + "The intraocular pressure was within the normal range.", + "Slit lamp examination revealed that the anterior segmental structures of both eyes were normal.", + "Ultrasound of the eye suggested flocculent vitreous clouding in the lower part of the right eye.", + "Partial signal enhancement in the retina of the left eye was found on optical coherence tomography (OCT).", + "Part of the photoreceptor cell layer was missing on OCT.", + "Fundus photography revealed a yellowish-white exudate with haemorrhage in the peripheral retina of the right eye.", + "Fundus photography revealed a faint haemorrhage in the lower retina of the left eye.", + "We highly suspected that the patient had developed cytomegalovirus retinitis.", + "We performed anterior atrial puncture and extracted aqueous humour from the patient for viral testing on 23 April.", + "We further refined FFA + ICGA on 25 April.", + "Using broad-spectrum high-throughput sequencing, the aqueous humour of her right eye tested positive for three viral DNAs—CMV, EBV, and HSV.", + "The left eye was positive for CMV only.", + "Internal markings and no template control were added to rule out false detection of both herpes viruses during the high-throughput sequencing.", + "The FFA + ICGA findings indicated a small amount of retinal exudate in the patient’s right eye.", + "The FFA + ICGA findings indicated a large area of obscured fluorescence in the subnasal and inferior choroid.", + "The patient was treated with bilateral vitreous cavity ganciclovir injections.", + "Viral DNA was retested one week later and no virus was detected in the aqueous humour of either eye by quantitative polymerase chain reaction (QPCR).", + "The test was negative for viral DNA.", + "OCT and fundus photography indicated no significant changes in the fundus.", + "The patient underwent weekly serum cytomegalovirus and EBV testing after the second stem cell transplant.", + "She was cytomegalovirus positive only between 15 November 2022 and 14 January 2023.", + "Viral copy numbers ranged from 1.02 × 102 to 2.37 × 104 during this period.", + "Each test was negative for EBV.", + "The patient was treated with systemic antiviral therapy in the hematology department since February 2023.", + "As of 22 May 2023, her fundal lesions all remained stable." + ], + "summary": "A 39-year-old female patient developed retinitis after a second haematopoietic stem cell transplant. Right eye was tested for three viral infections- cytomegalovirus, Epstein‒Barr virus and herpes simplex virus, while left was infected with cytomegalovirus. The patient was subsequently treated with vitreous cavity ganciclovir injections, and 1 week later both eyes tested negative for aqueous humour viruses.", + "summary_subclaims": [ + "The patient is a 39-year-old female.", + "The patient developed retinitis after a second haematopoietic stem cell transplant.", + "Right eye was tested for three viral infections: cytomegalovirus, Epstein‒Barr virus and herpes simplex virus.", + "Left eye was infected with cytomegalovirus.", + "The patient was treated with vitreous cavity ganciclovir injections.", + "One week later, both eyes tested negative for aqueous humour viruses." + ] + }, + { + "id": "multiclinsum_test_3017_en.txt", + "fulltext": "A 35-year-old African (Congolese) woman was admitted to the Panzi Hospital with a 4-day history of continuous urinary incontinence and dysuria, having previously been continent. The patient described a violent sensation of tearing whilst voiding and a popping sensation akin to the opening of a bottle cap immediately prior to becoming incontinent with blood-stained urine.\n\nClinical Findings and Diagnostic Investigations\nThe patient was G9/P9 with her last normal childbirth 18 months prior to presentation. There was no evidence of genital prolapse and otherwise she had no significant medical or surgical history. On arrival, she looked unwell. Her BP was 95/64 mmHg, pulse rate at 126 beats per minute, temperature 36°C and BMI 17.6.\n\nInitial vaginal examination revealed labia stained with urine and blood. There was a suburethral haematoma above a 2 cm vesico-vaginal fistula. We noted severe anemia (Hb: 6.4 g/dL). In addition, her urine culture was negative.\n\nManagement\nShe was treated immediately on arrival with two units blood transfusion and became hemodynamically stable antibiotic therapy, hygienic and dietary measures were instituted. After two weeks of conservative measures, the edges of the fistula became clean and rosy, delineating a semi-circumferential fistula involving a portion of the trigone, the bladder neck and the urethra. The urethral length was 1.3cm, the vesico-vaginal fistula size was 3.5cm with the ureters situated 0.5 cm from the edge. She underwent an examination under anaesthetic after initial resuscitation and biopsies were taken for the edge of the fistula. A double check analysis was done in two regional pathology laboratories. Biopsy results revealed a squamous mucosa with an epithelium without notable histological lesions. The dermis was characterized by extensive angiogenic activity, congestion and mixed moderate inflammatory infiltrates diagnostic of lobular capillary hemangioma.\n\nWe performed a repair of the vesico-urethro-vaginal fistula, using sharp dissection after the incision around the edge of the fistula. The ureters were protected with ureteric stents. The bladder was mobilized and the edge of the fistula trimmed. In contrast to classic obstetrical and gynecological traumatic fistula repair, the bladder wall on this fistula was found to be haemorrhagic and friable. Haemostasis was obtained using diathermy. Interrupted sutures in one layer were performed using vicryl 2/0 with longitudinal approximation of the fistula edges and the reconstruction of the vesico-urethral junction by lengthening the urethra (narrowing) under a metallic catheter. The urethral length established was approximately 3.5cm. A size 12 French Foley bladder indwelling catheter was left for 14 days. After a negative dye test, the vaginal mucosa was closed. A vaginal pack was placed for 24 hours.\n\n\nOutcome\nFollowing her catheter removal, the patient was able to void normally with no stress or urge incontinence. She received counseling on fistula prevention as well as contraception. Genital examination was normal and she was discharged 48 hours later. We reviewed the patient 3 months post operatively and found that she was continent with no voiding dysfunction.", + "fulltext_subclaims": [ + "The patient was a 35-year-old African (Congolese) woman.", + "She was admitted to the Panzi Hospital.", + "She had a 4-day history of continuous urinary incontinence.", + "She had a 4-day history of dysuria.", + "She had previously been continent.", + "The patient described a violent sensation of tearing whilst voiding.", + "The patient described a popping sensation akin to the opening of a bottle cap immediately prior to becoming incontinent.", + "She became incontinent with blood-stained urine.", + "The patient was G9/P9.", + "Her last normal childbirth was 18 months prior to presentation.", + "There was no evidence of genital prolapse.", + "On arrival, she looked unwell.", + "Her blood pressure was 95/64 mmHg.", + "Her pulse rate was 126 beats per minute.", + "Her temperature was 36°C.", + "Her BMI was 17.6.", + "Initial vaginal examination revealed labia stained with urine and blood.", + "There was a suburethral haematoma above a 2 cm vesico-vaginal fistula.", + "Severe anemia was noted with Hb: 6.4 g/dL.", + "Her urine culture was negative.", + "She was treated immediately on arrival with two units blood transfusion.", + "She became hemodynamically stable.", + "Antibiotic therapy was instituted.", + "Hygienic and dietary measures were instituted.", + "After two weeks of conservative measures, the edges of the fistula became clean and rosy.", + "The fistula delineated a semi-circumferential fistula involving a portion of the trigone, the bladder neck and the urethra.", + "The urethral length was 1.3cm.", + "The vesico-vaginal fistula size was 3.5cm.", + "The ureters were situated 0.5 cm from the edge.", + "An examination under anaesthetic was performed after initial resuscitation.", + "Biopsies were taken for the edge of the fistula.", + "A double check analysis was done in two regional pathology laboratories.", + "Biopsy results revealed a squamous mucosa with an epithelium without notable histological lesions.", + "The dermis was characterized by extensive angiogenic activity, congestion and mixed moderate inflammatory infiltrates diagnostic of lobular capillary hemangioma.", + "A repair of the vesico-urethro-vaginal fistula was performed.", + "The ureters were protected with ureteric stents.", + "The bladder was mobilized.", + "The edge of the fistula was trimmed.", + "The bladder wall on this fistula was found to be haemorrhagic and friable.", + "Haemostasis was obtained using diathermy.", + "Interrupted sutures in one layer were performed using vicryl 2/0.", + "The fistula edges were longitudinally approximated.", + "The vesico-urethral junction was reconstructed by lengthening the urethra under a metallic catheter.", + "The urethral length established was approximately 3.5cm.", + "A size 12 French Foley bladder indwelling catheter was left for 14 days.", + "After a negative dye test, the vaginal mucosa was closed.", + "A vaginal pack was placed for 24 hours.", + "Following her catheter removal, the patient was able to void normally.", + "She had no stress or urge incontinence.", + "She received counseling on fistula prevention.", + "She received counseling on contraception.", + "Genital examination was normal.", + "She was discharged 48 hours later.", + "She was reviewed 3 months post operatively.", + "She was continent.", + "She had no voiding dysfunction." + ], + "summary": "We report an unusual case of female genital fistula secondary to a lobular capillary hemangioma. A 35-year-old Congolese woman presented with urinary incontinence associated with a vaginal \"tearing\" sensation during micturition. A suburethral vascular bud and vesico-vaginal fistula were observed on examination. Over 2 weeks, the fistula enlarged to involve the trigone and bladder neck, resulting in a semi-circumferential urethro-vesico-vaginal fistula. Histology revealed a lobular capillary hemangioma. During fistula repair, the edges with vascular clusters were freshened, the genital fistula was closed and the woman became continent of urine.", + "summary_subclaims": [ + "We report an unusual case of female genital fistula secondary to a lobular capillary hemangioma.", + "A 35-year-old Congolese woman presented with urinary incontinence associated with a vaginal 'tearing' sensation during micturition.", + "A suburethral vascular bud and vesico-vaginal fistula were observed on examination.", + "Over 2 weeks, the fistula enlarged to involve the trigone and bladder neck.", + "Histology revealed a lobular capillary hemangioma.", + "During fistula repair, the edges with vascular clusters were freshened.", + "The genital fistula was closed.", + "The woman became continent of urine." + ] + }, + { + "id": "multiclinsum_test_205_en.txt", + "fulltext": "A 68-year-old man underwent right lower lobectomy for invasive mucinous adenocarcinoma (pT2aN1M0 Stage IIB) in June 2016 by an open thoracotomy approach. Postoperative follow-up computed tomography (CT) examinations revealed a pure-solid pulmonary nodule in the right upper lobe of his lung , which was found to be slightly enlarged on a follow-up CT evaluation . In July 2019, a partial pulmonary resection of the right upper lobe was performed. During the surgery, a severe adhesion between the lung and the chest wall was noted, and dissection of the adhesion caused bleeding from the 6th intercostal artery . Hemostasis was achieved using soft coagulation . Dissection of the adhesion was performed only to the extent necessary to perform the partial resection. The postoperative course was uneventful, and the patient was discharged 5 days after surgery.\nThe first postoperative outpatient visit was 18 days after surgery, and blood test and chest X-ray showed no abnormal findings. However, the patient later experienced hemoptysis at the toilet of a convenience store adjacent to the hospital. He was rushed to the hospital by medical staff who were assembled by a stat call. His vital scores were unstable; blood pressure (BP) was 117/98 mmHg, heart rate (HR) was 125 bpm, respiratory rate (RR) was 30 beats/min, and SpO2 was 70% (room air). A second chest X-ray on the same day showed decreased permeability in the right middle lung field . Contrast-enhanced CT scan of the chest showed a hematoma with a maximum diameter of 11 cm in the right thoracic cavity, a small amount of free air, and leakage of contrast medium into the hematoma from 6th intercostal artery . A 3D-reconstruction of the chest CT revealed a pseudoaneurysm of the intercostal artery .\nThe patient was immediately admitted to the Radiology Department for emergency angiography. Because his systolic BP was 58 mmHg on admittance, a rapid transfusion of four units of red cell concentrate (RCC) was administered during the preparation for angiography. The angiography through the right femoral artery revealed extravasation from the 6th intercostal artery . Therefore, the 6th intercostal artery was embolized using an embolization agent (NBCA:lipiodol = 1:3) to stop the bleeding.\nAfter the emergency angiography, the patient’s general condition recovered. However, a CT examination performed 2 days later found free air within the hematoma. Because pulmonary fistula was suspected, a chest drain tube (24Fr.) was inserted into the intrathoracic cavity. The air leak disappeared on day 17 after angiography and the patient was discharged on day 22.", + "fulltext_subclaims": [ + "A 68-year-old man underwent right lower lobectomy for invasive mucinous adenocarcinoma (pT2aN1M0 Stage IIB) in June 2016 by an open thoracotomy approach.", + "Postoperative follow-up computed tomography (CT) examinations revealed a pure-solid pulmonary nodule in the right upper lobe of his lung.", + "The nodule was found to be slightly enlarged on a follow-up CT evaluation.", + "In July 2019, a partial pulmonary resection of the right upper lobe was performed.", + "During the surgery, a severe adhesion between the lung and the chest wall was noted.", + "Dissection of the adhesion caused bleeding from the 6th intercostal artery.", + "Hemostasis was achieved using soft coagulation.", + "Dissection of the adhesion was performed only to the extent necessary to perform the partial resection.", + "The postoperative course was uneventful, and the patient was discharged 5 days after surgery.", + "The first postoperative outpatient visit was 18 days after surgery.", + "Blood test and chest X-ray showed no abnormal findings.", + "The patient later experienced hemoptysis at the toilet of a convenience store adjacent to the hospital.", + "He was rushed to the hospital by medical staff who were assembled by a stat call.", + "His blood pressure was 117/98 mmHg.", + "His heart rate was 125 bpm.", + "His respiratory rate was 30 beats/min.", + "His SpO2 was 70% (room air).", + "A second chest X-ray on the same day showed decreased permeability in the right middle lung field.", + "Contrast-enhanced CT scan of the chest showed a hematoma with a maximum diameter of 11 cm in the right thoracic cavity.", + "Contrast-enhanced CT scan showed a small amount of free air.", + "Contrast-enhanced CT scan showed leakage of contrast medium into the hematoma from 6th intercostal artery.", + "A 3D-reconstruction of the chest CT revealed a pseudoaneurysm of the intercostal artery.", + "The patient was immediately admitted to the Radiology Department for emergency angiography.", + "His systolic BP was 58 mmHg on admittance.", + "A rapid transfusion of four units of red cell concentrate (RCC) was administered during the preparation for angiography.", + "The angiography through the right femoral artery revealed extravasation from the 6th intercostal artery.", + "The 6th intercostal artery was embolized using an embolization agent (NBCA:lipiodol = 1:3) to stop the bleeding.", + "After the emergency angiography, the patient’s general condition recovered.", + "A CT examination performed 2 days later found free air within the hematoma.", + "Because pulmonary fistula was suspected, a chest drain tube (24Fr.) was inserted into the intrathoracic cavity.", + "The air leak disappeared on day 17 after angiography.", + "The patient was discharged on day 22." + ], + "summary": "A 68-year-old man, with a history of right lower lobectomy 3 years prior, underwent a partial resection of the right upper lobe for a pulmonary nodule suspicious for secondary lung cancer. During the surgery, dissection of the adhesion caused a bleeding from the 6th intercostal artery, and hemostasis was achieved using soft coagulation (some degree of tissue carbonization was noticed at later mortality and morbidity conference). He experienced hemoptysis at postoperative day 18 and was transferred to our hospital. Contrast-enhanced CT scan revealed bleeding from the pseudoaneurysm of the 6th intercostal artery. Embolization was performed by angiography to stop the bleeding.", + "summary_subclaims": [ + "The patient is a 68-year-old man.", + "The patient had a right lower lobectomy 3 years prior.", + "The patient underwent a partial resection of the right upper lobe.", + "The pulmonary nodule was suspicious for secondary lung cancer.", + "During the surgery, dissection of the adhesion caused bleeding from the 6th intercostal artery.", + "Hemostasis was achieved using soft coagulation.", + "Some degree of tissue carbonization was noticed at later mortality and morbidity conference.", + "The patient experienced hemoptysis at postoperative day 18.", + "Contrast-enhanced CT scan revealed bleeding from the pseudoaneurysm of the 6th intercostal artery.", + "Embolization was performed by angiography to stop the bleeding." + ] + }, + { + "id": "multiclinsum_test_850_en.txt", + "fulltext": "An 11-year-old boy who was diagnosed with MS was referred to our clinic with the complaint of reduced vision in his left eye. He had noticed a decreased vision in his left eye following a mild head trauma 2 weeks prior to our visit. He was found to have optic nerve swelling and was referred to a neurologist. Neurological examinations were normal. Brain magnetic resonance imaging (MRI) revealed high T2/FLAIR intensity lesions at juxta-cortical, subcortical, and periventricular white matter, as well as corpus callosum, calloso-septal interface and cervical and thoracic spinal cord without restricted-diffusion or enhancement (Supplementary Fig. 1). The diagnosis of pediatric-onset MS (POMS) was established by an MS specialist. Intravenous (IV) methylprednisolone (1g daily for 5 days) was administered, but his vision did not improve prompting referral to our center.\nIn ophthalmologic examination in our clinic, the patient's visual acuity (VA) was 6/10 in the right and finger counting (FC) at 50 cm in the left eye. Anterior segment examination revealed bilateral mild injection of conjunctiva. There were no cells in the anterior chamber (AC). The intraocular pressure (IOP) measurements were within normal limits. A prominent relative afferent pupillary defect (RAPD) was present in the left eye. Vitreous organization, 2 + vitreous cells and haze, snowballs and snowbanks were observed in both eyes.\nIn fundus examination, the left optic disc had blurred margins along with peripapillary hemorrhage. The right eye optic nerve examination was unremarkable . Perivascular sheathing in the peripheral retina could be appreciated in both eyes.\nRetinal nerve fiber layer (RNFL) optical coherence tomography (OCT) scans revealed remarkable increase in the left eye optic nerve head RNFL thickness . Macular spectral domain (SD)-OCT illustrated the posterior vitreous cells; Both eyes exhibited perifoveal non-cystic retinal thickening, which could potentially serve as an indicator of significant peripheral retinal vascular leakage, as suggested by a recent study . In fluorescein angiography, optic disc leakage, periphlebitis and vascular leakage in equator and more predominantly in the periphery of the retina were observed bilaterally; no macular leakage was evident..\nAll laboratory testing including PPD, ACE, VDRL and RPR were reported within normal range or non-reactive.\nThe patient was diagnosed with bilateral POMS associated intermediate uveitis. Considering active uveitis despite receiving high dose systemic corticosteroid, posterior sub-Tenon triamcinolone acetonide (20 mg/0.5 ml) was administered to each eye.\nAt the same time, the patient was treated with another IV methylprednisolone (1 g daily for 3 days) and also plasmapheresis for five sessions in neurology ward; the treatment was continued with Rituximab (prescribed as 500 mg, IV infusion separated by two weeks and then every 6 months).\nAfter four months, the patient's vision improved to 10/10 and 9/10 in the right and left eye, respectively. The intensity of vitreous cells and haze decreased to 0.5 + in both eyes. At 4 months follow-up, fluorescein angiography demonstrated that optic disc and vascular leakage had subsided bilaterally .", + "fulltext_subclaims": [ + "An 11-year-old boy who was diagnosed with MS was referred to our clinic with the complaint of reduced vision in his left eye.", + "He had noticed a decreased vision in his left eye following a mild head trauma 2 weeks prior to our visit.", + "He was found to have optic nerve swelling and was referred to a neurologist.", + "Neurological examinations were normal.", + "Brain magnetic resonance imaging (MRI) revealed high T2/FLAIR intensity lesions at juxta-cortical, subcortical, and periventricular white matter, as well as corpus callosum, calloso-septal interface and cervical and thoracic spinal cord without restricted-diffusion or enhancement.", + "The diagnosis of pediatric-onset MS (POMS) was established by an MS specialist.", + "Intravenous (IV) methylprednisolone (1g daily for 5 days) was administered.", + "His vision did not improve prompting referral to our center.", + "The patient's visual acuity (VA) was 6/10 in the right and finger counting (FC) at 50 cm in the left eye.", + "Anterior segment examination revealed bilateral mild injection of conjunctiva.", + "There were no cells in the anterior chamber (AC).", + "The intraocular pressure (IOP) measurements were within normal limits.", + "A prominent relative afferent pupillary defect (RAPD) was present in the left eye.", + "Vitreous organization, 2 + vitreous cells and haze, snowballs and snowbanks were observed in both eyes.", + "The left optic disc had blurred margins along with peripapillary hemorrhage.", + "The right eye optic nerve examination was unremarkable.", + "Perivascular sheathing in the peripheral retina could be appreciated in both eyes.", + "Retinal nerve fiber layer (RNFL) optical coherence tomography (OCT) scans revealed remarkable increase in the left eye optic nerve head RNFL thickness.", + "Macular spectral domain (SD)-OCT illustrated the posterior vitreous cells.", + "Both eyes exhibited perifoveal non-cystic retinal thickening, which could potentially serve as an indicator of significant peripheral retinal vascular leakage, as suggested by a recent study.", + "In fluorescein angiography, optic disc leakage, periphlebitis and vascular leakage in equator and more predominantly in the periphery of the retina were observed bilaterally.", + "No macular leakage was evident.", + "All laboratory testing including PPD, ACE, VDRL and RPR were reported within normal range or non-reactive.", + "The patient was diagnosed with bilateral POMS associated intermediate uveitis.", + "Considering active uveitis despite receiving high dose systemic corticosteroid, posterior sub-Tenon triamcinolone acetonide (20 mg/0.5 ml) was administered to each eye.", + "The patient was treated with another IV methylprednisolone (1 g daily for 3 days) and also plasmapheresis for five sessions in neurology ward.", + "The treatment was continued with Rituximab (prescribed as 500 mg, IV infusion separated by two weeks and then every 6 months).", + "After four months, the patient's vision improved to 10/10 and 9/10 in the right and left eye, respectively.", + "The intensity of vitreous cells and haze decreased to 0.5 + in both eyes.", + "At 4 months follow-up, fluorescein angiography demonstrated that optic disc and vascular leakage had subsided bilaterally." + ], + "summary": "An 11-year-old boy who was diagnosed with Pediatric-onset MS (POMS) with the first presentation of left optic neuritis in another center, was referred to our clinic with the complaint of non-improved vision in the left eye despite receiving IV 5gr methylprednisolone. After the ophthalmologic examinations, the patient was diagnosed as bilateral POMS-associated intermediate uveitis, and local treatment with corticosteroid was administered to both eyes. He was continued on systemic therapy such as Rituximab and five sessions of plasmapheresis. After four months, the patient's vision improved from FC at 50cm to 9/10 in the left eye. The intensity of intraocular inflammation decreased in both eyes. In fluorescein angiography findings, the optic disc, as well as vascular leakage, subsided bilaterally.", + "summary_subclaims": [ + "The patient is an 11-year-old boy.", + "The patient was diagnosed with Pediatric-onset MS.", + "The first presentation was left optic neuritis.", + "The patient was referred to our clinic with the complaint of non-improved vision in the left eye.", + "The patient received IV 5gr methylprednisolone.", + "The patient was diagnosed as bilateral POMS-associated intermediate uveitis.", + "Local treatment with corticosteroid was administered to both eyes.", + "The patient was continued on systemic therapy such as Rituximab.", + "The patient received five sessions of plasmapheresis.", + "After four months, the patient's vision improved from FC at 50cm to 9/10 in the left eye.", + "The intensity of intraocular inflammation decreased in both eyes.", + "In fluorescein angiography findings, the optic disc subsided bilaterally.", + "In fluorescein angiography findings, vascular leakage subsided bilaterally." + ] + }, + { + "id": "multiclinsum_test_3167_en.txt", + "fulltext": "The patient was a 79-year-old female with NYHA class III heart failure with non-ischemic cardiomyopathy (LVEF 40%) and chronic atrial fibrillation who was referred for CardioMEMS implantation. She had been hospitalized 3 times for heart failure in the prior year despite receiving outpatient intravenous diuretic therapy at the heart failure infusion clinic. Warfarin was held for 3 days prior to the implant procedure and her international normalized ratio (INR) was 1.8 on the day of the procedure. She was taking 81 mg aspirin daily. The remainder of her laboratory studies were unremarkable.\n\nGiven her obesity and body habitus, we chose the right internal jugular venous approach for the implant procedure. Right heart catheterization was performed and showed right atrial pressure of 5 mm Hg, pulmonary artery systolic/diastolic/mean pressures of 40/14/22 mm Hg respectively and a pulmonary capillary wedge pressure of 12 mm Hg. A 12 F sheath was placed in the right internal jugular vein and 4000 units of intravenous heparin was administered. Diluted contrast injection through the Swan-Ganz catheter identified a suitable sized left lower lobe branch pulmonary artery. A 0.018-inch wire was advanced into the index artery and the pressure sensor was deployed at the chosen location. The procedure was completed uneventfully. The patient started coughing 20 minutes after the procedure with evolved to mild hemoptysis and so the patient was transferred to the cardiac intensive care unit for observation. Intravenous protamine was administered to reverse heparin. She was kept off warfarin and aspirin and the hemoptysis resolved 3 days later. While the exact etiology of hemoptysis in this patient is unclear, we felt that it may have been precipitated by a minor wire-induced distal branch pulmonary artery injury.", + "fulltext_subclaims": [ + "The patient was a 79-year-old female with NYHA class III heart failure with non-ischemic cardiomyopathy.", + "The patient had chronic atrial fibrillation.", + "The patient was referred for CardioMEMS implantation.", + "She had been hospitalized 3 times for heart failure in the prior year.", + "Warfarin was held for 3 days prior to the implant procedure.", + "Her international normalized ratio (INR) was 1.8 on the day of the procedure.", + "She was taking 81 mg aspirin daily.", + "We chose the right internal jugular venous approach for the implant procedure.", + "Right heart catheterization showed a pulmonary capillary wedge pressure of 12 mm Hg.", + "A 12 F sheath was placed in the right internal jugular vein.", + "4000 units of intravenous heparin was administered.", + "Diluted contrast injection through the Swan-Ganz catheter identified a suitable sized left lower lobe branch pulmonary artery.", + "A 0.018-inch wire was advanced into the index artery.", + "The pressure sensor was deployed at the chosen location.", + "The procedure was completed uneventfully.", + "The patient started coughing 20 minutes after the procedure.", + "The patient had mild hemoptysis.", + "The patient was transferred to the cardiac intensive care unit for observation.", + "Intravenous protamine was administered to reverse heparin.", + "The patient was kept off warfarin and aspirin.", + "The hemoptysis resolved 3 days later.", + "The exact etiology of hemoptysis in this patient is unclear.", + "We felt that the hemoptysis may have been precipitated by a minor wire-induced distal branch pulmonary artery injury." + ], + "summary": "Patient: Female, 79\n\nFinal Diagnosis: Hemoptysis\n\nSymptoms: Hemoptysis\n\nMedication: —\n\nClinical Procedure: —\n\nThe patient was a 79-year-old female with NYHA class III heart failure with non-ischemic cardiomyopathy (LVEF 40%) and chronic atrial fibrillation who was referred for CardioMEMS implantation. The procedure was completed uneventfully. The patient was transferred out of the procedure suite to the recovery area where she developed a slight cough approximately 20 minutes after the implantation. Within a few coughs the patient started having hemoptysis. She was transferred to the cardiac intensive care unit for observation. She was kept off warfarin and aspirin and her hemoptysis resolved 3 days later. While the exact etiology of hemoptysis in this patient was unclear, we felt that it may have been precipitated by a minor wire-induced distal branch pulmonary artery injury.", + "summary_subclaims": [ + "The patient was a 79-year-old female.", + "The patient had NYHA class III heart failure.", + "The patient had non-ischemic cardiomyopathy.", + "The patient's LVEF was 40%.", + "The patient had chronic atrial fibrillation.", + "The patient was referred for CardioMEMS implantation.", + "The CardioMEMS implantation procedure was completed uneventfully.", + "The patient was transferred to the recovery area after the procedure.", + "The patient developed a slight cough approximately 20 minutes after the implantation.", + "The patient started having hemoptysis within a few coughs.", + "The patient was transferred to the cardiac intensive care unit.", + "The patient was kept off warfarin.", + "The patient was kept off aspirin.", + "The patient's hemoptysis resolved 3 days later.", + "The exact etiology of hemoptysis in this patient was unclear.", + "We felt that the hemoptysis may have been precipitated by a minor wire-induced distal branch pulmonary artery injury." + ] + }, + { + "id": "multiclinsum_test_1101_en.txt", + "fulltext": "This 2-year-old boy was the third son of non-consanguineous healthy Italian parents. He was born at the fortieth gestational week after an uneventful pregnancy and a spontaneous delivery. Family history was negative for neurological diseases or congenital birth defects. One and five minute Apgar scores were respectively 9 and 10. Birth weight was 3450 g (35–50th percentile), birth length was 55 cm (97th percentile) and head circumference was 33 cm (10th percentile). At birth, bilateral metatarsus varus was evident, requiring conservative orthopedic treatment. No further bone deformities were noticed. He was referred to our attention at age of 8 months for daily, brief episodes of generalized hypertonia and staring. Dysmorphic features of the face were observed, such as arched eyebrows, down-slanting palpebral fissures, anteverted nostrils, depressed nasal bridge, wide philtrum, and arched thin upper lip . A single cafè-au-lait spot was present on left thigh. Neurological evaluation showed axial hypotonia. Microcephaly was not present. Developmental milestones were mildly delayed: the baby controlled his head at age 5 months, but could not be seated without support. An ictal video-electroencephalogram (EEG) revealed normal findings for age and excluded an epileptic origin of the events. Subsequently, at the age of 9 months, he developed daily episodes of psychomotor arrest, palpebral myoclonias, oral automatisms (e.g., chewing) rarely coupled with vibratory hypertonus. Sleep and awake interictal video-EEGs showed a normal background activity with epileptiform anomalies in bilateral central regions. Therapy with levetiracetam was started and titrated to 40 mg/kg/day. Brain magnetic resonance imaging revealed corpus callosum hypoplasia and enlargement of fronto-temporal sub-arachnoids spaces. Cardiac, abdominal and pelvic (including liver, spleen, gall bladder, pancreas and bladder) ultrasound findings were unremarkable. Eye examination revealed no abnormalities. Routinary biochemical analysis, electrocardiogram, auditory brainstem response and visual evoked potential and electroretinogram yielded normal results. Valproic acid (30 mg/kg/die) and, successively, clonazepam (0.6 mg/die) were added to levetiracetam since daily seizures persisted.\nAt last follow-up the child is 2 year old. Seizures are controlled by levetiracetam, valproic acid and clonazepam and recurred twice during febrile episodes. Language delay is present: he is able to pronounce 3–5 words. Motor development is improved: he can stand and walk autonomously.", + "fulltext_subclaims": [ + "The patient is a 2-year-old boy.", + "He was the third son of non-consanguineous healthy Italian parents.", + "He was born at the fortieth gestational week.", + "The pregnancy was uneventful.", + "The delivery was spontaneous.", + "Family history was negative for neurological diseases.", + "Family history was negative for congenital birth defects.", + "One-minute Apgar score was 9.", + "Five-minute Apgar score was 10.", + "Birth weight was 3450 g.", + "Birth weight was in the 35–50th percentile.", + "Birth length was 55 cm.", + "Birth length was in the 97th percentile.", + "Head circumference was 33 cm.", + "Head circumference was in the 10th percentile.", + "Bilateral metatarsus varus was evident at birth.", + "Bilateral metatarsus varus required conservative orthopedic treatment.", + "No further bone deformities were noticed.", + "He was referred at age of 8 months.", + "He had daily, brief episodes of generalized hypertonia.", + "He had daily, brief episodes of staring.", + "Dysmorphic features of the face were observed.", + "A single cafè-au-lait spot was present on left thigh.", + "Neurological evaluation showed axial hypotonia.", + "Microcephaly was not present.", + "Developmental milestones were mildly delayed.", + "He controlled his head at age 5 months.", + "He could not be seated without support.", + "An ictal video-electroencephalogram (EEG) revealed normal findings for age.", + "An ictal video-EEG excluded an epileptic origin of the events.", + "At age of 9 months, he developed daily episodes of psychomotor arrest.", + "At age of 9 months, he developed palpebral myoclonias.", + "At age of 9 months, he developed oral automatisms.", + "Sleep and awake interictal video-EEGs showed a normal background activity.", + "Sleep and awake interictal video-EEGs showed epileptiform anomalies in bilateral central regions.", + "Therapy with levetiracetam was started.", + "Levetiracetam was titrated to 40 mg/kg/day.", + "Brain magnetic resonance imaging revealed corpus callosum hypoplasia.", + "Brain magnetic resonance imaging revealed enlargement of fronto-temporal sub-arachnoid spaces.", + "Cardiac, abdominal and pelvic ultrasound findings were unremarkable.", + "Eye examination revealed no abnormalities.", + "Routinary biochemical analysis yielded normal results.", + "Electrocardiogram yielded normal results.", + "Auditory brainstem response yielded normal results.", + "Visual evoked potential yielded normal results.", + "Electroretinogram yielded normal results.", + "Valproic acid (30 mg/kg/day) was added to levetiracetam.", + "Clonazepam (0.6 mg/day) was added to levetiracetam.", + "Seizures are controlled by levetiracetam, valproic acid and clonazepam.", + "Seizures recurred twice during febrile episodes.", + "Language delay is present.", + "He is able to pronounce 3–5 words.", + "He can stand and walk autonomously." + ], + "summary": "In this paper we report on a patient with a de novo interstitial deletion of 5.5 Mb at 14q24.3-q31.1. The deletion encompasses 84 genes, including fourteen Mendelian genes. He presented with dysmorphic face, developmental delay, paroxysmal non-epileptic events and, subsequently, epilepsy.", + "summary_subclaims": [ + "The patient has a de novo interstitial deletion of 5.5 Mb at 14q24.3-q31.1.", + "The deletion encompasses 84 genes.", + "The deletion includes fourteen Mendelian genes.", + "The patient presented with dysmorphic face.", + "The patient had developmental delay.", + "The patient had paroxysmal non-epileptic events.", + "The patient subsequently developed epilepsy." + ] + }, + { + "id": "multiclinsum_test_657_en.txt", + "fulltext": "A 49-year-old female patient presented to the outpatient clinic with headache for 11 d, and left upper and lower extremity weakness accompanied by fever for 1 wk.\nThe patient had persistent pain mainly due to right frontal and parietal headache, which could not be relieved after rest. The patient was hospitalized at the Department of Neurology with a body temperature of 39.2 ℃.\nThe patient had type 2 diabetes. A diagnostic consultation did not identify any foci of infection. She had no past history of otitis media, sinusitis, or head trauma.\nThe patient denied having any other relevant personal history and her familial history was unremarkable.\nThe physical examination revealed intact consciousness with a Glasgow coma scale (GCS) score of 15, a soft neck, left upper and lower extremity muscular strength (1 out of 5), a shallow left nasolabial fold, and intact deep and superficial sensation.\nA complete blood count with differential revealed a white blood cell count of 13.4 × 109/L (normal reference range: 4.0–10.0 × 109/L), 80.0% neutrophils (normal reference range: 50%–70%), 12.1% lymphocytes (normal reference range: 20%–40%), and C-reactive protein level of 50.1 mg/L (normal reference range: 0–10 mg/L). Urinalysis revealed a white blood cell count of 229/μg (normal reference range: 0-26/μg). Urine culture grew Enterococcus faecalis. Blood and sputum cultures were negative.\nNo obvious abnormalities were observed in a computed tomography (CT) scan of the chest. Cardiac Doppler ultrasound revealed mild mitral regurgitation. Magnetic resonance imaging (MRI) of the head with and without contrast demonstrated the following: (1) Large-scale abnormal signal lesions in the right frontal lobe and right basal ganglia with low signal on T1-weigted imaging, slightly higher signal on T2-weigted imaging, and high signal on diffusion-weighted imaging (DWI); (2) Enhancement of the gyrus around the lesion without significant space-occupying effect; and (3) Multiple long T2 signals and enhanced DWI signals in the left cerebral hemisphere . CT angiography of cervical arteries demonstrated occlusion of the right internal carotid artery . Further examination of the arteries by magnetic resonance angiography showed that there was no development of the right internal carotid artery skull base and intracranial segments, and the anterior and posterior cerebral arteries were supplied by the traffic branch .\nAll available clinical evidence up to this point suggested cerebral infarction, with the only unexplained symptoms being persistent fever and headache. Per antibacterial susceptibility testing of the urine culture, piperacillin and tazobactam were administered intravenously, in addition to the initiation of standard treatment for cerebral infarction. In the following week, the patient's temperature fluctuated between 38 ℃ and 39 ℃, and her headache did not improve significantly. Two consecutive cerebrospinal fluid tests revealed the following: (1) Greater than 100 nucleated cells, most of which were neutrophils; (2) Slightly elevated glucose and protein levels; (3) Normal chloride levels; and (4) Opening pressures of 170 mmH2O and 210 mmH2O. No bacteria or fungi were found in cultures of the cerebrospinal fluid. Considering the possibility of brain abscess, the patient was empirically treated with meropenem and vancomycin. However, as discussed above, a CT scan of the head showed a low-density shadow in the right frontal lobe and right basal ganglia. The right basal ganglia showed focal enhancement, the right lateral ventricle was slightly compressed, and there was slight midline shift to the left. In light of these findings, 100 mL intravenous mannitol, 250 mL intravenous glycerol fructose, and intravenous sodium chloride were infused every 12 h. The patient's temperature continued to fluctuate between 37 ℃ and 38 ℃, and her headache persisted. Approximately 1 wk later, the patient's temperature suddenly rose to 39 ℃. A review of the head CT revealed a large area of infarction corresponding to the right middle cerebral artery. The density of some areas was slightly higher, the midline was shifted, and cerebral palsy developed . Accordingly, right craniotomy and drainage were performed, with turbid serosanguineous fluid and no signs of abscess observed intraoperatively. After 1 wk, the patient's level of consciousness decreased (GCS, E3V4M4). Repeat MRI of the head was still consistent with cerebral infarction . However, after communicating with the patient's family, resection of the right brain lesion was performed and tissue was sent for gross pathologic and histologic examination. Findings reported by pathology included purulent brain tissue with visible fungal structures revealed by special staining to be consistent with mucormycosis . On the 10th d after the brain lesion resection, repeat head CT showed a large low-density shadow, and the midline returned to normal .", + "fulltext_subclaims": [ + "The patient was a 49-year-old female.", + "The patient presented with headache for 11 d.", + "The patient had left upper and lower extremity weakness.", + "The patient had fever for 1 wk.", + "The patient had persistent pain mainly due to right frontal and parietal headache.", + "The patient's headache could not be relieved after rest.", + "The patient was hospitalized at the Department of Neurology.", + "The patient's body temperature was 39.2 ℃.", + "The patient had type 2 diabetes.", + "A diagnostic consultation did not identify any foci of infection.", + "The patient had no past history of otitis media.", + "The patient had no past history of sinusitis.", + "The patient had no past history of head trauma.", + "The patient denied having any other relevant personal history.", + "The patient's familial history was unremarkable.", + "The physical examination revealed a Glasgow coma scale (GCS) score of 15.", + "The physical examination revealed left upper and lower extremity muscular strength of 1 out of 5.", + "The physical examination revealed a shallow left nasolabial fold.", + "The complete blood count with differential revealed a white blood cell count of 13.4 × 109/L.", + "The complete blood count with differential revealed 80.0% neutrophils.", + "The complete blood count with differential revealed 12.1% lymphocytes.", + "The C-reactive protein level was 50.1 mg/L.", + "Urinalysis revealed a white blood cell count of 229/μg.", + "Urine culture grew Enterococcus faecalis.", + "Blood and sputum cultures were negative.", + "No obvious abnormalities were observed in a computed tomography (CT) scan of the chest.", + "Cardiac Doppler ultrasound revealed mild mitral regurgitation.", + "Magnetic resonance imaging (MRI) of the head with and without contrast demonstrated large-scale abnormal signal lesions in the right frontal lobe and right basal ganglia.", + "The MRI showed low signal on T1-weighted imaging.", + "The MRI showed slightly higher signal on T2-weighted imaging.", + "The MRI showed high signal on diffusion-weighted imaging (DWI).", + "The MRI showed enhancement of the gyrus around the lesion.", + "The MRI showed multiple long T2 signals in the left cerebral hemisphere.", + "The MRI showed enhanced DWI signals in the left cerebral hemisphere.", + "CT angiography of cervical arteries demonstrated occlusion of the right internal carotid artery.", + "Magnetic resonance angiography showed no development of the right internal carotid artery skull base and intracranial segments.", + "The anterior and posterior cerebral arteries were supplied by the traffic branch.", + "All available clinical evidence up to this point suggested cerebral infarction.", + "The only unexplained symptoms were persistent fever and headache.", + "Piperacillin and tazobactam were administered intravenously.", + "Standard treatment for cerebral infarction was initiated.", + "The patient's temperature fluctuated between 38 ℃ and 39 ℃.", + "The patient's headache did not improve significantly.", + "Two consecutive cerebrospinal fluid tests revealed greater than 100 nucleated cells, most of which were neutrophils.", + "Two consecutive cerebrospinal fluid tests revealed slightly elevated glucose and protein levels.", + "Two consecutive cerebrospinal fluid tests revealed normal chloride levels.", + "Two consecutive cerebrospinal fluid tests revealed opening pressures of 170 mmH2O and 210 mmH2O.", + "No bacteria or fungi were found in cultures of the cerebrospinal fluid.", + "The patient was empirically treated with meropenem and vancomycin.", + "A CT scan of the head showed a low-density shadow in the right frontal lobe and right basal ganglia.", + "The right basal ganglia showed focal enhancement.", + "The right lateral ventricle was slightly compressed.", + "There was slight midline shift to the left.", + "100 mL intravenous mannitol, 250 mL intravenous glycerol fructose, and intravenous sodium chloride were infused every 12 h.", + "The patient's temperature continued to fluctuate between 37 ℃ and 38 ℃.", + "The patient's headache persisted.", + "Approximately 1 wk later, the patient's temperature suddenly rose to 39 ℃.", + "A review of the head CT revealed a large area of infarction corresponding to the right middle cerebral artery.", + "The density of some areas was slightly higher.", + "The midline was shifted.", + "Cerebral palsy developed.", + "Right craniotomy and drainage were performed.", + "Turbid serosanguineous fluid was observed intraoperatively.", + "No signs of abscess were observed intraoperatively.", + "After 1 wk, the patient's level of consciousness decreased (GCS, E3V4M4).", + "Repeat MRI of the head was still consistent with cerebral infarction.", + "Resection of the right brain lesion was performed.", + "Tissue was sent for gross pathologic and histologic examination.", + "Pathology findings included purulent brain tissue.", + "Special staining revealed visible fungal structures.", + "The fungal structures were consistent with mucormycosis.", + "On the 10th d after the brain lesion resection, repeat head CT showed a large low-density shadow.", + "The midline returned to normal." + ], + "summary": "Cerebral mucormycosis is generally secondary to sinus disease or other disseminated disease. However, in this retrospective study, we report and analyze a case of isolated cerebral mucormycosis.", + "summary_subclaims": [ + "Cerebral mucormycosis is generally secondary to sinus disease or other disseminated disease.", + "In this retrospective study, we report and analyze a case of isolated cerebral mucormycosis." + ] + }, + { + "id": "multiclinsum_test_1193_en.txt", + "fulltext": "Physical examination on admission: Obese 61-year-old woman (BMI 30.1 kg/m2), pulse 60/min, blood pressure 120/80 mmHg, temperature 36 °C, O2 saturation 94% under mechanical ventilation. Heart, lungs, and abdomen unremarkable. Laboratory studies: Complete blood count: unremarkable. Plasma coagulation study: normal, D-dimers within normal limits, Clinical chemistry: C-reactive protein 6 mg/L (normal 5 mg/L), all other values within normal limits. ECG: Sinus rhythm, HF 60, no AV-Block, no QT time prolongation, inverted T-waves in the inferior leads (III, aVF) . Fast echocardiography: Normal systolic right and left ventricular systolic function, severe mitral regurgitation, no pericardial effusion. Chest x-ray: Normal cardiac size with evidence of pulmonary venous congestion.\nIntensive care therapy achieved stabilization of the patient’s general condition. Controlled ventilation was stopped on the fourth day. Except for a hypoactive delirium, which was adequately controlled by administration of a neuroleptikum, no neurological deficits were manifested.\nEvaluation of the 12-lead ECG did not reveal any evidence of ECG changes, which are normally associated with canalopathies (Brugada, ARVC, long-, short QT syndromes etc.).\nHowever, we have registered recurrent ventricular salves during monitoring . In addition, we registered a short-lasting atrial fibrillation with spontaneous termination . Therefore, oral anticoagulation was initiated.\nFollow-up echocardiography showed a significant mitral valve insufficiency with preserved left ventricular pump function. The left ventricle demonstrated mild endsystolic and enddiastolic dilatation. A severe dilatation of the left atrium (LA area 45 cm2) was noticed . The lateral mitral annular velocities was quantified with Doppler tissue imaging. The peak systolic lateral mitral annulus velocity was 18 cm/s .\nTransesophageal echocardiography was performed to evaluate the mitral valve more precisely. A high-grade eccentric mitral valve insufficiency due to a pronounced PML and a mild AML prolapse could be demonstrated . Especially the PML showed thickening and myxomatous changes . The tendinous chordae appeared to be intact.\nFor further clarification of the arrhythmogenic event, we ordered a CMR. This exploration has shown a discreet mid-wall LGE in the LV inferobasal region . Additionally, LGE of the PM was visible on mid short-axis view . The right ventricle showed no pathology by echocardiography and CMR. A significant mitral annulus disjunction (MAD) measuring 11,2 mm was identified. .\nRegarding the severe mitral valvular insufficiency due to the MVP, the case was discussed in the heart team. It was decided to provide the patient with an internal automatic cardioverter defibrillator (ICD) first and to repair the mitral valve by mini invasive surgery in 3 months.\nThe patient showed regression of the delirium and an increasing mobility. After implantation of an ICD device , the patient was discharged in good general condition and without significant neurological deficits. A cardio-neurological rehabilitation was organized. The first ICD follow-up analysis after 3 Weeks did not show any arrhythmogenic events. At the 3 months ICD follow up, few days after the mitral valve reconstruction, we detected a VT, which has been successfully electrocardioverted .", + "fulltext_subclaims": [ + "The patient is a 61-year-old woman.", + "The patient's BMI is 30.1 kg/m2.", + "The patient's oxygen saturation is 94% under mechanical ventilation.", + "The patient's ECG shows inverted T-waves in the inferior leads (III, aVF).", + "The patient's fast echocardiography shows severe mitral regurgitation.", + "The patient's chest x-ray shows evidence of pulmonary venous congestion.", + "The patient's controlled ventilation was stopped on the fourth day.", + "The patient had a hypoactive delirium.", + "The patient's delirium was adequately controlled by administration of a neuroleptikum.", + "The patient's 12-lead ECG did not reveal any evidence of ECG changes associated with canalopathies.", + "The patient had recurrent ventricular salves during monitoring.", + "The patient had a short-lasting atrial fibrillation with spontaneous termination.", + "Oral anticoagulation was initiated.", + "Follow-up echocardiography showed significant mitral valve insufficiency.", + "The left ventricle demonstrated mild endsystolic and enddiastolic dilatation.", + "A severe dilatation of the left atrium (LA area 45 cm2) was noticed.", + "The peak systolic lateral mitral annulus velocity was 18 cm/s.", + "Transesophageal echocardiography showed a high-grade eccentric mitral valve insufficiency due to a pronounced PML and a mild AML prolapse.", + "The PML showed thickening and myxomatous changes.", + "The tendinous chordae appeared to be intact.", + "The CMR showed a discreet mid-wall LGE in the LV inferobasal region.", + "The CMR showed LGE of the PM on mid short-axis view.", + "A significant mitral annulus disjunction (MAD) measuring 11.2 mm was identified.", + "The patient was provided with an internal automatic cardioverter defibrillator (ICD).", + "The patient was scheduled for mitral valve repair by mini invasive surgery in 3 months.", + "The patient was discharged in good general condition.", + "The patient had a cardio-neurological rehabilitation organized.", + "The first ICD follow-up analysis after 3 weeks did not show any arrhythmogenic events.", + "At the 3-month ICD follow-up, a VT was detected.", + "The VT was successfully electrocardioverted." + ], + "summary": "We report on a 61-year-old female patient who had undergone an aborted sudden cardiac death. An arrythmogenic mitral valve prolapse was diagnosed. In addition, electrocardiographically and morphologically risk markers for sudden cardiac death were found in this case. We performed an ICD implantation as secondary prophylaxis and intended to reconstruct the mitral valve.", + "summary_subclaims": [ + "We report on a 61-year-old female patient who had undergone an aborted sudden cardiac death.", + "An arrythmogenic mitral valve prolapse was diagnosed.", + "Electrocardiographically and morphologically risk markers for sudden cardiac death were found in this case.", + "We performed an ICD implantation as secondary prophylaxis.", + "We intended to reconstruct the mitral valve." + ] + }, + { + "id": "multiclinsum_test_420_en.txt", + "fulltext": "A 63-year-old Japanese man who had cardiomyopathy of unknown etiology experienced ventricular tachycardia, and an implantable cardioverter defibrillator (ICD) was thus implanted. The ventricular lead was fixed on his RV high septum, because a low-voltage area extended across his mid- to low-ventricular septum. The pacing mode of the ICD was programmed to AAI mode. The width of his own QRS wave was 120ms. His echocardiogram showed a severely dilated and diffuse hypokinetic left ventricle. His septal wall was thin and high-echoic. Cardiac sarcoidosis was suspected, but the diagnostic criteria could not be fulfilled. Three years after ICD implantation, he developed dyspnea until he experienced New York Heart Association (NYHA) class III heart failure. A Wenckebach-type second-degree atrioventricular block was observed during atrium-only pacing at 60 beats per minute (Figure ), therefore, the pacing mode was programmed to DDDR mode. After changing the pacing mode, his symptoms apparently worsened, and he was admitted the following week. He experienced NYHA class IV heart failure, and his electrocardiogram showed dissociated biphasic QRS morphology (Figure ). The width of the first component of the QRS wave was 110ms, and that of the second component was 102ms. His echocardiogram showed severe interventricular dyssynchrony. LV ejection occurred 150ms later than did RV ejection.\nEndocardial substrate mapping by the CARTO™ XP system (Biosense Webster Inc., Diamond Bar, CA, USA) showed a low-voltage area extended across his basal to mid-ventricular septum. Activation mapping of his own QRS wave (Figure A) showed that ventricular conduction started at his mid-septum, and both LV and RV excitation ended simultaneously within 166ms. However, activation mapping during RV high-septal pacing (Figure C) showed that RV conduction started at the pacing site and ended at the RV basal inferior site within 83ms after the pacing stimulus. Subsequently after a 10ms interval, LV conduction started at his basal posterior septum and ended at the lateral wall within 226ms after the pacing stimulus. These data show that in RV high-septal pacing, the first component of the QRS wave supposedly reflects only RV excitation originating at the RV high septum, and the second component reflects only LV excitation originating at the LV posteroseptum. His electrocardiogram (ECG) also showed biphasic QRS morphology during LV lateral or RV apical pacing. This interventricular dyssynchrony was improved by biventricular pacing, therefore, his ICD was upgraded to cardiac resynchronization therapy with defibrillator (CRTD; Figure ). Two years after upgrading to CRTD, he showed good hemodynamic conditions and improved to NYHA class II.", + "fulltext_subclaims": [ + "The patient was a 63-year-old Japanese man.", + "He had cardiomyopathy of unknown etiology.", + "He experienced ventricular tachycardia.", + "An implantable cardioverter defibrillator (ICD) was implanted.", + "The ventricular lead was fixed on his RV high septum.", + "A low-voltage area extended across his mid- to low-ventricular septum.", + "The pacing mode of the ICD was programmed to AAI mode.", + "The width of his own QRS wave was 120ms.", + "His echocardiogram showed a severely dilated and diffuse hypokinetic left ventricle.", + "His septal wall was thin and high-echoic.", + "Cardiac sarcoidosis was suspected.", + "The diagnostic criteria could not be fulfilled.", + "Three years after ICD implantation, he developed dyspnea until he experienced New York Heart Association (NYHA) class III heart failure.", + "A Wenckebach-type second-degree atrioventricular block was observed during atrium-only pacing at 60 beats per minute.", + "The pacing mode was programmed to DDDR mode.", + "After changing the pacing mode, his symptoms apparently worsened.", + "He was admitted the following week.", + "He experienced NYHA class IV heart failure.", + "His electrocardiogram showed dissociated biphasic QRS morphology.", + "The width of the first component of the QRS wave was 110ms.", + "The width of the second component of the QRS wave was 102ms.", + "His echocardiogram showed severe interventricular dyssynchrony.", + "LV ejection occurred 150ms later than did RV ejection.", + "Endocardial substrate mapping by the CARTO™ XP system showed a low-voltage area extended across his basal to mid-ventricular septum.", + "Activation mapping of his own QRS wave showed that ventricular conduction started at his mid-septum.", + "Both LV and RV excitation ended simultaneously within 166ms.", + "Activation mapping during RV high-septal pacing showed that RV conduction started at the pacing site.", + "RV conduction ended at the RV basal inferior site within 83ms after the pacing stimulus.", + "Subsequently after a 10ms interval, LV conduction started at his basal posterior septum.", + "LV conduction ended at the lateral wall within 226ms after the pacing stimulus.", + "These data show that in RV high-septal pacing, the first component of the QRS wave supposedly reflects only RV excitation originating at the RV high septum.", + "The second component reflects only LV excitation originating at the LV posteroseptum.", + "His electrocardiogram also showed biphasic QRS morphology during LV lateral or RV apical pacing.", + "This interventricular dyssynchrony was improved by biventricular pacing.", + "His ICD was upgraded to cardiac resynchronization therapy with defibrillator (CRTD).", + "Two years after upgrading to CRTD, he showed good hemodynamic conditions.", + "He improved to NYHA class II." + ], + "summary": "We report a case of 63-year-old Japanese man with cardiomyopathy with an implantable cardioverter defibrillator placement for ventricular tachycardia. Three years after implantation, he developed second-degree atrio-ventricular block. Therefore, atrio-ventricular sequential pacing was started; then his heart failure was much worsened. His electrocardiogram showed a dissociated biphasic QRS wave during right ventricular high-septal pacing, despite the presence of a non-fragmented QRS morphology during atrium-only pacing. An activation map during right ventricular high-septal pacing showed that right ventricular conduction started at the pacing site and ended at the right ventricular basal inferior site. Subsequently after a 10 ms interval, left ventricular conduction started at the left ventricular posteroseptum and ended at the left ventricular lateral wall. These data indicate that during right ventricular high-septal pacing, the first component of the QRS wave supposedly reflects only right ventricular excitation and the second component only left ventricular excitation. Also due to the intracardiac electrograms, it was assumed that this phenomenon was caused by transversely limited severe transseptal conduction disturbance.", + "summary_subclaims": [ + "The patient is a 63-year-old Japanese man.", + "The patient has cardiomyopathy.", + "The patient had an implantable cardioverter defibrillator placed for ventricular tachycardia.", + "Three years after implantation, the patient developed second-degree atrio-ventricular block.", + "Atrio-ventricular sequential pacing was started.", + "Heart failure was much worsened after starting atrio-ventricular sequential pacing.", + "The electrocardiogram showed a dissociated biphasic QRS wave during right ventricular high-septal pacing.", + "During atrium-only pacing, the QRS morphology was non-fragmented.", + "An activation map during right ventricular high-septal pacing showed that right ventricular conduction started at the pacing site.", + "Right ventricular conduction ended at the right ventricular basal inferior site.", + "Subsequently after a 10 ms interval, left ventricular conduction started at the left ventricular posteroseptum.", + "Left ventricular conduction ended at the left ventricular lateral wall.", + "The first component of the QRS wave supposedly reflects only right ventricular excitation.", + "The second component of the QRS wave supposedly reflects only left ventricular excitation.", + "It was assumed that this phenomenon was caused by transversely limited severe transseptal conduction disturbance." + ] + }, + { + "id": "multiclinsum_test_2896_en.txt", + "fulltext": "A 56-year-old male initially presented with aphasia and right hemiparesis. Head CT, and brain magnetic resonance imaging (MRI) revealed a left thalamic intracerebral hemorrhage with intraventricular extension . No AVM was detected on MR angiography (MRA). Given the high suspicion for an underlying vascular lesion, DSA was performed, which revealed enlargement of the left anterior choroidal artery and early drainage into the left internal cerebral vein with no discernible nidus, likely due to the concurrent hematoma . The patient recovered his language and motor function over the next 3 months.\nDiagnostic DSA and CBCT performed 3 months after presentation demonstrated a Spetzler-Martin Grade III left thalamic AVM [Figure , and ]. The 5 mm nidus was predominantly supplied by the left anterior choroidal artery and to a lesser degree by a thalamoperforator from the left posterior communicating artery. Deep venous drainage was through the internal cerebral vein. Planned stereotactic radiosurgery (SRS) was delayed for 3 months due to an unrelated severe knee injury resulting in a lower extremity deep venous thrombosis.\nSix months after presentation, MRI and MRA performed for SRS planning did not demonstrate the AVM, or the previously seen flow enhancement of the thalamus on MRA. Seven months after initial presentation, DSA and CBCT confirmed the spontaneous angiographic resolution of the AVM [Figure and ] without treatment. The patient was subsequently lost to follow-up.", + "fulltext_subclaims": [ + "A 56-year-old male initially presented with aphasia and right hemiparesis.", + "Head CT and brain magnetic resonance imaging (MRI) revealed a left thalamic intracerebral hemorrhage with intraventricular extension.", + "No AVM was detected on MR angiography (MRA).", + "Given the high suspicion for an underlying vascular lesion, DSA was performed.", + "DSA revealed enlargement of the left anterior choroidal artery.", + "DSA revealed early drainage into the left internal cerebral vein.", + "DSA did not demonstrate a discernible nidus.", + "The patient recovered his language and motor function over the next 3 months.", + "Diagnostic DSA and CBCT performed 3 months after presentation demonstrated a Spetzler-Martin Grade III left thalamic AVM.", + "The 5 mm nidus was predominantly supplied by the left anterior choroidal artery.", + "The nidus was supplied to a lesser degree by a thalamoperforator from the left posterior communicating artery.", + "Deep venous drainage was through the internal cerebral vein.", + "Planned stereotactic radiosurgery (SRS) was delayed for 3 months.", + "The delay was due to an unrelated severe knee injury.", + "The knee injury resulted in a lower extremity deep venous thrombosis.", + "MRI and MRA performed for SRS planning did not demonstrate the AVM.", + "MRI and MRA did not demonstrate the previously seen flow enhancement of the thalamus on MRA.", + "DSA and CBCT confirmed the spontaneous angiographic resolution of the AVM.", + "The AVM resolution occurred without treatment.", + "The patient was lost to follow-up." + ], + "summary": "We report the case of a 56-year-old male who presented with aphasia and right hemiparesis secondary to intracerebral and intraventricular hemorrhage. Diagnostic digital subtraction angiography (DSA) and c-arm cone beam computed tomography (CBCT) demonstrated a 5 mm Spetzler-Martin Grade III left thalamic AVM drained by the internal cerebral vein. Subsequent DSA and CBCT studies confirmed the spontaneous obliteration of the AVM.", + "summary_subclaims": [ + "The patient was a 56-year-old male.", + "The patient presented with aphasia.", + "The patient had right hemiparesis.", + "The hemiparesis was secondary to intracerebral and intraventricular hemorrhage.", + "Diagnostic digital subtraction angiography was performed.", + "C-arm cone beam computed tomography was performed.", + "The AVM was 5 mm in size.", + "The AVM was Spetzler-Martin Grade III.", + "The AVM was located in the left thalamus.", + "The AVM was drained by the internal cerebral vein.", + "Subsequent DSA and CBCT studies confirmed the spontaneous obliteration of the AVM." + ] + }, + { + "id": "multiclinsum_test_1207_en.txt", + "fulltext": "A 37-year-old woman was admitted to our hospital on September 15, 2020 due to recurrent cough for more than 10 mo.\nThe patient developed a paroxysmal cough accompanied by a small amount of white sputum 10 mo ago. She had no chills, fever, chest pain, hemoptysis, or shortness of breath. She received symptomatic treatment such as anti-infection at a local hospital but her symptoms persisted during this period. The above symptoms recurred 1 mo ago with a little yellow sputum. Fever and hemoptysis were absent. The patient was admitted to our hospital for further treatment.\nThe patient was thin and weighed only 40 kg (Body mass index: 15.6). Her temperature was 37.4 °C, pulse rate was 99 bpm, respiratory rate was 19 breaths/min, and blood pressure was 100/63 mmHg. No clubbing of fingers, icterus, or generalized lymphadenopathy were observed. Clinical examinations of the cardiovascular, gastrointestinal, and nervous systems were normal, but crackles were found in the lower lobe of the left lung during lung auscultation.\nLaboratory studies showed normal white blood cells (8.6 × 109/L), and the neutrophil ratio was 83.0%. Erythrocyte sedimentation rate was 26 mm/h (normal value < 15 mm/h), and high-sensitivity C-reactive protein was 8.2 mg/L (normal value < 8.0 mg/L). Arterial partial pressure of oxygen was 91 mmHg (partial pressure of oxygen/fraction of inspiration O2 433.3 mmHg), and arterial partial pressure of carbon dioxide was 41 mmHg. The 1,3-β-D-glucan test and galactomannan test were both negative.\nEnhanced computed tomography images revealed a honeycomb lesion in the lower lobe of the left lung, and an enhanced vascular shadow was seen in the descending aorta, which was consistent with pulmonary sequestration .\nWe also performed bronchoscopic alveolar lavage in the posterior basal segment of the left lower lobe. Gram-positive bacilli were detected in the bronchoalveolar lavage fluid (BALF) . The modified acid-fast staining of BALF was weakly positive, and the possible presence of Nocardia species was considered. Following culture of BALF, N. cyriacigeorgica was identified , which was confirmed by matrix-assisted laser desorption ionization-time of flight mass spectrometry (matrix-assisted laser desorption/ ionization-time of flight; VITEK MS, bioMérieux, Craponne, France) .", + "fulltext_subclaims": [ + "The patient is a 37-year-old woman.", + "She was admitted to the hospital on September 15, 2020.", + "She had a recurrent cough for more than 10 months.", + "The cough was paroxysmal and accompanied by a small amount of white sputum.", + "The patient had no chills, fever, chest pain, hemoptysis, or shortness of breath.", + "She received symptomatic treatment such as anti-infection at a local hospital.", + "Her symptoms persisted during this period.", + "The symptoms recurred 1 month ago with a little yellow sputum.", + "Fever and hemoptysis were absent.", + "The patient was admitted to the hospital for further treatment.", + "Her weight was 40 kg.", + "Her body mass index was 15.6.", + "Her temperature was 37.4 °C.", + "Her pulse rate was 99 bpm.", + "Her respiratory rate was 19 breaths/min.", + "Her blood pressure was 100/63 mmHg.", + "No clubbing of fingers, icterus, or generalized lymphadenopathy were observed.", + "Clinical examinations of the cardiovascular, gastrointestinal, and nervous systems were normal.", + "Crackles were found in the lower lobe of the left lung during lung auscultation.", + "White blood cells were 8.6 × 109/L.", + "The neutrophil ratio was 83.0%.", + "Erythrocyte sedimentation rate was 26 mm/h.", + "High-sensitivity C-reactive protein was 8.2 mg/L.", + "Arterial partial pressure of oxygen was 91 mmHg.", + "Arterial partial pressure of carbon dioxide was 41 mmHg.", + "The 1,3-β-D-glucan test was negative.", + "The galactomannan test was negative.", + "Enhanced computed tomography images revealed a honeycomb lesion in the lower lobe of the left lung.", + "An enhanced vascular shadow was seen in the descending aorta.", + "The findings were consistent with pulmonary sequestration.", + "Bronchoscopic alveolar lavage was performed in the posterior basal segment of the left lower lobe.", + "Gram-positive bacilli were detected in the bronchoalveolar lavage fluid.", + "The modified acid-fast staining of bronchoalveolar lavage fluid was weakly positive.", + "The possible presence of Nocardia species was considered.", + "N. cyriacigeorgica was identified following culture of bronchoalveolar lavage fluid.", + "The identification was confirmed by matrix-assisted laser desorption ionization-time of flight mass spectrometry." + ], + "summary": "A 37-year-old woman complaining of a recurrent cough was admitted to our hospital. Pulmonary sequestration in the lower lobe of the left lung was diagnosed by enhanced computed tomography. Bronchoalveolar lavage fluid was then collected, which showed gram positive bacilli with weakly positive modified acid-fast staining. The pathogen was identified as N. cyriacigeorgica after bacterial culture and mass spectrometry analysis. The patient was diagnosed with pulmonary sequestration complicated with N. cyriacigeorgica infection, and her symptoms quickly improved following anti-infective therapy.", + "summary_subclaims": [ + "A 37-year-old woman complaining of a recurrent cough was admitted to our hospital.", + "Pulmonary sequestration in the lower lobe of the left lung was diagnosed by enhanced computed tomography.", + "Bronchoalveolar lavage fluid was then collected.", + "Gram positive bacilli with weakly positive modified acid-fast staining were seen.", + "The pathogen was identified as N. cyriacigeorgica after bacterial culture and mass spectrometry analysis.", + "The patient was diagnosed with pulmonary sequestration complicated with N. cyriacigeorgica infection.", + "The patient's symptoms quickly improved following anti-infective therapy." + ] + }, + { + "id": "multiclinsum_test_1192_en.txt", + "fulltext": "The subject described in this case report is a 21-year-old male who suffered a concussion 356 days prior to the physical therapy evaluation. The injury occurred during a fall out of a moving golf cart onto his left shoulder/neck region. The subject reported loss of consciousness and post-traumatic amnesia following the injury. The subject was taken to a local emergency department and CT scan results appeared negative for cerebral bleeding but identified a left temporal bone fracture not requiring medical intervention. The subject received no education on symptomology or symptom duration, and no referral or follow-up was scheduled at the time of discharge. The subject reported a history of four previous concussions, three of which were sport-related, but otherwise had no co-morbidities or significant past medical history. Only minor residual symptoms from his previous concussions were reported that all gradually resolved. The subject had constant, persistent symptoms since the injury that impaired his abilities in school as well as his social life and had restricted athletic or recreational activities, reducing his overall quality of life. The subject visited his primary physician a few weeks prior to evaluation; his cervical spine was cleared via radiographs, and he was referred to a metropolitan outpatient physical therapy clinic.\nThe subject was given the Rivermead Post-Concussion Questionnaire (RPQ) to assess symptomology. The RPQ is a subjective, self-report measure that encompasses 16 items, each of which is scored from 0-4 in increasing severity, assessing separate cognitive, emotional, and somatic physical factors. The RPQ demonstrates high test-retest and inter-rater reliability for both total score and individual items via spearman rank correlation coefficients (r = 0.91, r = 0.87 respectively). The subject’s chief reported symptoms during the initial evaluation were neck pain and stiffness, bilateral radicular symptoms that were worse in the left shoulder and upper extremity, lightheadedness, nausea, dizziness, blurred vision and diplopia, sensitivity to light, impaired balance, slurred speech, trouble sleeping, fatigue, slower thinking, and frustration. The subject’s primary complaint was his headache symptoms, which the subject reported were brought on by reading, scanning, driving, or cervical movements. The subject also reported a period of gradual worsening during the weeks and months following his injury. The subject’s goals for physical therapy were to reduce the severity of symptoms experienced since the injury, primarily concerning his headache, fatigue, and neck pain symptomology, as he reported these symptoms have impacted his abilities as a college student and decreased his participation in his social life.\nThe subject described in this case report provided informed consent for the study and was informed that the data collected would be used for publication. This study has been approved by the Mercer University Institutional Review Board and Office of Research Compliance. The primary author providing patient care and clinical decision making was a student physical therapist at the time of subject interaction and was supervised by a licensed physical therapist.", + "fulltext_subclaims": [ + "The subject described in this case report is a 21-year-old male.", + "The subject suffered a concussion 356 days prior to the physical therapy evaluation.", + "The injury occurred during a fall out of a moving golf cart onto his left shoulder/neck region.", + "The subject reported loss of consciousness.", + "The subject reported post-traumatic amnesia.", + "The subject was taken to a local emergency department.", + "CT scan results appeared negative for cerebral bleeding.", + "CT scan identified a left temporal bone fracture.", + "The left temporal bone fracture did not require medical intervention.", + "The subject received no education on symptomology or symptom duration.", + "The subject had no referral or follow-up scheduled at the time of discharge.", + "The subject reported a history of four previous concussions.", + "Three of the subject's previous concussions were sport-related.", + "The subject had no co-morbidities.", + "The subject had no significant past medical history.", + "The subject had constant, persistent symptoms since the injury.", + "The subject visited his primary physician a few weeks prior to evaluation.", + "The subject's cervical spine was cleared via radiographs.", + "The subject was referred to a metropolitan outpatient physical therapy clinic.", + "The subject was given the Rivermead Post-Concussion Questionnaire (RPQ).", + "The RPQ is a subjective, self-report measure.", + "The RPQ encompasses 16 items.", + "Each item on the RPQ is scored from 0-4.", + "The RPQ assesses cognitive, emotional, and somatic physical factors.", + "The RPQ demonstrates high test-retest reliability via spearman rank correlation coefficients (r = 0.91).", + "The RPQ demonstrates high inter-rater reliability via spearman rank correlation coefficients (r = 0.87).", + "The subject's chief reported symptoms during the initial evaluation were neck pain and stiffness.", + "The subject's chief reported symptoms during the initial evaluation included bilateral radicular symptoms.", + "The subject's chief reported symptoms during the initial evaluation included lightheadedness.", + "The subject's chief reported symptoms during the initial evaluation included nausea.", + "The subject's chief reported symptoms during the initial evaluation included dizziness.", + "The subject's chief reported symptoms during the initial evaluation included blurred vision and diplopia.", + "The subject's chief reported symptoms during the initial evaluation included sensitivity to light.", + "The subject's chief reported symptoms during the initial evaluation included impaired balance.", + "The subject's chief reported symptoms during the initial evaluation included slurred speech.", + "The subject's chief reported symptoms during the initial evaluation included trouble sleeping.", + "The subject's chief reported symptoms during the initial evaluation included fatigue.", + "The subject's chief reported symptoms during the initial evaluation included slower thinking.", + "The subject's primary complaint was his headache symptoms.", + "The subject's headache symptoms were brought on by reading.", + "The subject's headache symptoms were brought on by scanning.", + "The subject's headache symptoms were brought on by driving.", + "The subject's headache symptoms were brought on by cervical movements.", + "The subject reported a period of gradual worsening during the weeks and months following his injury.", + "The subject's goals for physical therapy were to reduce the severity of symptoms experienced since the injury.", + "The subject's goals for physical therapy primarily concerned his headache, fatigue, and neck pain symptomology.", + "The subject described in this case report provided informed consent for the study.", + "The subject was informed that the data collected would be used for publication.", + "This study has been approved by the Mercer University Institutional Review Board.", + "This study has been approved by the Mercer University Office of Research Compliance.", + "The primary author providing patient care and clinical decision making was a student physical therapist.", + "The primary author was supervised by a licensed physical therapist." + ], + "summary": "This case describes a 21-year-old male who sustained a concussion 356 days prior to evaluation. He received no follow-up treatment and reported periods of worsening symptoms since the injury. Impairments in cervical range of motion and accessory mobility, vestibular and vestibulo-ocular function, and postural stability were identified. Both cognitive and emotional symptoms were also present. The patient attended eight, sixty-minute sessions over a five-week period in an outpatient setting. Comprehensive physical therapy interventions included manual therapy, vestibular rehabilitation, and neuromotor retraining aimed at restoring proper sensory integration and midline postural orientation.", + "summary_subclaims": [ + "The patient is a 21-year-old male.", + "The patient sustained a concussion 356 days prior to evaluation.", + "The patient received no follow-up treatment.", + "The patient reported periods of worsening symptoms since the injury.", + "Impairments in cervical range of motion were identified.", + "Impairments in accessory mobility were identified.", + "Impairments in vestibular and vestibulo-ocular function were identified.", + "Impairments in postural stability were identified.", + "Cognitive symptoms were present.", + "Emotional symptoms were present.", + "The patient attended eight, sixty-minute sessions over a five-week period.", + "The sessions occurred in an outpatient setting.", + "Comprehensive physical therapy interventions included manual therapy.", + "Comprehensive physical therapy interventions included vestibular rehabilitation.", + "Comprehensive physical therapy interventions included neuromotor retraining.", + "The interventions aimed at restoring proper sensory integration.", + "The interventions aimed at restoring midline postural orientation." + ] + }, + { + "id": "multiclinsum_test_447_en.txt", + "fulltext": "A 75-year-old man presented with fever and right chest pain. The blood biochemical tests showed the following: lactate dehydrogenase (LDH), 251 IU/L; alkaline phosphatase (ALP), 469 IU/L; gamma-glutamyl transferase (γ-GTP), 125 IU/L; creatinine (Cre) 1.43 mg/dL; C-reactive protein (CRP) 3.04 mg/dL; squamous cell carcinoma-related antigen (SCC), 1.8 ng/mL; nerve specific enolase (NSE), 21.6 ng/mL; soluble interleukin-2 receptor (SIL-2R), 614 U/mL. Computed tomography (CT) showed a huge 10-cm mass under the right diaphragm . This well-circumscribed and smooth-marginated tumor showed minor enhancement in the lower density areas close to the fat and showed a gradual, heterogeneous mild enhancement of tumor and liver margins. The main feeder for the tumor is the right inferior phrenic artery, and this tumor was supposed to be a sarcomatoid malignancy originating from the diaphragm rather than a benign disease such as schwannoma on CT. No findings were suggesting obvious pulmonary invasion. Magnetic resonance imaging (MRI) demonstrated heterogeneous high signal intensity on T2-weighted images (T2WI) and diffusion-weighted images (DWI) . Contrast-enhanced MRI showed gradual heterogeneous enhancement similar to CT findings. Findings of extrahepatic development were also obtained, but the possibility of adhesion to the liver was suspected. Fluorodeoxyglucose-positron emission tomography (FDG-PET) revealed abnormal uptake in the tumor with a maximal standardized uptake value (SUVmax) of 4.6 . The uptake was not so high, and a myxoid type sarcoma, such as myxoid liposarcoma, or benign tumor was considered. Although a definitive diagnosis could not be achieved, we scheduled a diaphragmatic resection for suspicion of benign tumors of the diaphragm, such as mucous-type sarcoma or schwannoma. However, we performed extended right posterior segmentectomy with combined resection of the diaphragm, because separation of the tumor from the liver was not possible and the tumor was close to the posterior Glisson’s pedicles and segment 8 dorsal Glisson’s pedicles . The total operation time was 8 h 10 m, and the total blood loss was 1459 mL. Although the major diameter of the diaphragmatic defect was 12 cm, simple closure was possible . The patient’s postoperative course was uneventful, and he was discharged 14 days after surgery. Pathological findings showed that the mass was located just below the hepatic capsule/intraparenchymal space and was adherent to the diaphragm, but there was no continuity with the diaphragm . Mitosis was unremarkable, about 0–1 cells/10 HPF. The morphology suggested low-grade mesenchymal tumors such as solitary fibrous tumor (SFT) and perivascular epithelioid cell tumor (PEComa) , but immunostaining was negative for these tumors, making the diagnosis difficult . We diagnosed the tumor as a spindle cell tumor with smooth muscle differentiation because of the positive results of myosin markers such as αSMA, desmin, and h-caldesmon, although some areas with high proliferative activity were observed. 1 year has passed since the surgery with no recurrence.", + "fulltext_subclaims": [ + "The patient is a 75-year-old man.", + "The patient presented with fever.", + "The patient presented with right chest pain.", + "The blood biochemical tests showed lactate dehydrogenase (LDH) of 251 IU/L.", + "The blood biochemical tests showed alkaline phosphatase (ALP) of 469 IU/L.", + "The blood biochemical tests showed gamma-glutamyl transferase (γ-GTP) of 125 IU/L.", + "The blood biochemical tests showed creatinine (Cre) of 1.43 mg/dL.", + "The blood biochemical tests showed C-reactive protein (CRP) of 3.04 mg/dL.", + "The blood biochemical tests showed squamous cell carcinoma-related antigen (SCC) of 1.8 ng/mL.", + "The blood biochemical tests showed nerve specific enolase (NSE) of 21.6 ng/mL.", + "The blood biochemical tests showed soluble interleukin-2 receptor (SIL-2R) of 614 U/mL.", + "Computed tomography (CT) showed a huge 10-cm mass under the right diaphragm.", + "The tumor showed minor enhancement in the lower density areas close to the fat.", + "The tumor showed gradual, heterogeneous mild enhancement of tumor and liver margins.", + "The main feeder for the tumor is the right inferior phrenic artery.", + "The tumor was supposed to be a sarcomatoid malignancy originating from the diaphragm.", + "No findings were suggesting obvious pulmonary invasion.", + "Magnetic resonance imaging (MRI) demonstrated heterogeneous high signal intensity on T2-weighted images (T2WI).", + "Magnetic resonance imaging (MRI) demonstrated heterogeneous high signal intensity on diffusion-weighted images (DWI).", + "Contrast-enhanced MRI showed gradual heterogeneous enhancement similar to CT findings.", + "Findings of extrahepatic development were also obtained.", + "The possibility of adhesion to the liver was suspected.", + "Fluorodeoxyglucose-positron emission tomography (FDG-PET) revealed abnormal uptake in the tumor with a maximal standardized uptake value (SUVmax) of 4.6.", + "The uptake was not so high.", + "A myxoid type sarcoma, such as myxoid liposarcoma, or benign tumor was considered.", + "A definitive diagnosis could not be achieved.", + "We scheduled a diaphragmatic resection for suspicion of benign tumors of the diaphragm.", + "We performed extended right posterior segmentectomy with combined resection of the diaphragm.", + "The total operation time was 8 h 10 m.", + "The total blood loss was 1459 mL.", + "The major diameter of the diaphragmatic defect was 12 cm.", + "Simple closure was possible.", + "The patient’s postoperative course was uneventful.", + "The patient was discharged 14 days after surgery.", + "Pathological findings showed the mass was located just below the hepatic capsule/intraparenchymal space.", + "The mass was adherent to the diaphragm.", + "There was no continuity with the diaphragm.", + "Mitosis was unremarkable, about 0–1 cells/10 HPF.", + "The morphology suggested low-grade mesenchymal tumors such as solitary fibrous tumor (SFT) and perivascular epithelioid cell tumor (PEComa).", + "Immunostaining was negative for these tumors.", + "The diagnosis was difficult.", + "The tumor was diagnosed as a spindle cell tumor with smooth muscle differentiation.", + "The diagnosis was based on positive results of myosin markers such as αSMA, desmin, and h-caldesmon.", + "Some areas with high proliferative activity were observed.", + "1 year has passed since the surgery with no recurrence." + ], + "summary": "A 75-year-old man presented with fever and right chest pain. He was suspected of a giant primary diaphragmatic tumor of extrahepatic origin by imaging studies. The preoperative differential diagnosis included benign masses such as myxoid sarcoma and schwannoma, and we planned a diaphragmatic resection. Intraoperatively, however, dissection of the tumor from the liver was not possible, requiring an extended right posterior segmentectomy with combined resection of the diaphragm. The patient had a good postoperative course and 1 year has passed since the surgery with no recurrence. The pathology showed that the mass was located just below the hepatic capsule/parenchymal region and was adherent to the diaphragm, but there was no continuity. The morphology suggested a low-grade mesenchymal tumor such as a solitary fibrous tumor and perivascular epithelioid cell tumor, but immunostaining was negative, making the diagnosis difficult. Although some areas of high proliferative activity were observed, finally, the diagnosis of primary spindle cell tumor of the liver with smooth muscle differentiation was made based on the positive results of muscle markers such as αSMA, desmin, and h-caldesmon.", + "summary_subclaims": [ + "A 75-year-old man presented with fever and right chest pain.", + "He was suspected of a giant primary diaphragmatic tumor of extrahepatic origin by imaging studies.", + "The preoperative differential diagnosis included benign masses such as myxoid sarcoma and schwannoma.", + "We planned a diaphragmatic resection.", + "Intraoperatively, dissection of the tumor from the liver was not possible.", + "An extended right posterior segmentectomy with combined resection of the diaphragm was required.", + "The patient had a good postoperative course.", + "One year has passed since the surgery with no recurrence.", + "The mass was located just below the hepatic capsule/parenchymal region.", + "The mass was adherent to the diaphragm, but there was no continuity.", + "The morphology suggested a low-grade mesenchymal tumor such as a solitary fibrous tumor and perivascular epithelioid cell tumor.", + "Immunostaining was negative.", + "Some areas of high proliferative activity were observed.", + "The diagnosis of primary spindle cell tumor of the liver with smooth muscle differentiation was made.", + "The diagnosis was based on the positive results of muscle markers such as αSMA, desmin, and h-caldesmon." + ] + }, + { + "id": "multiclinsum_test_1997_en.txt", + "fulltext": "A 62-year-old non-Asian Spanish man was admitted to the emergency room for abdominal pain of epigastric origin, which evolved over the next 3 days to diffuse pain with constipation, but with no fever or vomiting. He had a 32-pack-year smoking history and had completed disulfiram treatment for alcohol cessation 10 years previously. He had residual pain in lower limbs after lumbar disc herniation surgery 15 years previously, for which he was taking naproxen, and had a medical history of a mild factor XII deficiency. He had no other relevant medical, surgical, or family history. On physical examination, palpation showed he had a contracted abdomen, with lividity and signs of peritonism but with no signs of deep vein thrombosis in the lower limbs. Blood pressure was 112/88 mmHg, heart rate 122 beats per minute, and temperature 35.8 ℃. There were no other findings on physical and neurological examination. A thoracoabdominal computed tomography (CT) scan revealed “findings suggestive of intestinal perforation (probably in the upper hemiabdomen), without being able to clearly identify the point of perforation.” Laboratory parameters in the emergency room showed glucose 123 mg/dL, urea 238 mg/dL, creatinine 4.29 mg/dL (previously, normal), total bilirubin 1.45 mg/dL (conjugated 0.91 mg/dL), and amylase 111 mg/dL. Sodium and potassium were in normal range, and the hemogram was also normal. Intravenous fluid resuscitation and empiric antimicrobial therapy with piperacillin–tazobactam 3.375 g/8 hours intravenous for 10 days, fluconazole 400 mg/24 hours for 6 days, and vancomycin 1 g/12 hours for 4 days were started. The patient underwent urgent surgical intervention, which revealed generalized peritonitis, perforation at the pylorus, necrosis of the greater omentum, and an abundance of free fluid in all abdominal quadrants (surgical intervention consisted of pyloric suture and resection of the greater omentum). The pathology report revealed “pyloric wall with signs of perforation and epiplon with adiponecrosis, microabscesses and exudative-fibrinoid serositis.” In the immediate postoperative period, the patient had a low level of consciousness and saturation of up to 80%, with acute lung edema observed on the CT scan (“extensive bilateral pulmonary consolidations associated with bilateral pleural effusion and evidence of anasarca due to probable fluid overload/decompensated heart failure”). The patient was intubated to achieve oxygen saturation > 98% with an FiO2 of 0.4. The patient was sedated and on analgesic, responding to painful stimuli. Hemodynamically, he was mostly stable with a need for norepinephrine at 0.3 mg/kg/minute and tension readings of 123/73 and 90 beats per minute. However, liver function progressively worsened, reaching total bilirubin levels of 4.15 mg/dL. Likewise, the patient was in acute renal failure AKIN III, with diuresis dependent on furosemide at 30 mg/hour, creatinine levels > 4 mg/dL, and urea > 290 mg/dL. The patient presented poor postoperative course, with progressively higher fluid outflow through abdominal drains and abdominal sepsis, as revealed by symptoms and microbiology (Klebsiella pneumoniae was isolated in blood culture; Enterococcus faecalis and Escherichia coli in the drains; E. coli and Streptococcus anginosus in the surgical wound), which raised suspicion of perforation of the previous surgical suture. As intraabdominal pressure increased progressively, the patient underwent a second surgical intervention at 9 days after the first surgery, which revealed a biliopurulent contamination in the peritoneal cavity caused by a previous dehiscence from a pyloric suture line. Therefore, based on intraoperative findings, duodenal exclusion was performed by gastric antrectomy followed by retrocolic Roux-en-Y (end-to-side) gastrojejunostomy and jejunojejunal distal (side-to-side) anastomosis. Cholecystectomy was then followed by external drainage of the common bile duct by placement of a T-tube, to prevent cholecystitis. Splenectomy was performed because of intraoperative bleeding.\nThe patient remained intubated and sedated, maintaining good saturation. He also had hemodynamic stability without vasoactive amines. However, total bilirubin levels continued to rise (from 4.15 to 6.8 mg/dl), and the patient continued to exhibit anuria, with urea 291 mg/dl, creatinine 4.02 mg/dl; pH 7.35, HCO3- 26.5 mmol/L, pCO2 47 mmHg, and normal anion gap (AG). The patient began treatment with an infusion of caspofungin for 13 days at 50 mg/24 hours, meropenem for 21 days at 1 g/8 hours, and again with vancomycin for 6 days. As the patient again presented very poor postoperative evolution, with fecal contamination of the abdominal drainage, a third surgery was performed 4 days after the second one, in which the patient underwent partial colectomy (due to the intraoperative ischemic appearance of the colon) and resuture of the pyloric repair. Pathological anatomy showed gastric and duodenal dehiscence, with an ischemic appearance of the transverse colon and perforations, foci of hemorrhagic necrosis (both mucosal and submucosal), secondary gangrenous inflammation, and multiple intestinal ulcerations related to calcified phlebosclerosis of the submucosal vessels. After the third intervention, the patient was in stable but serious condition. Hemodynamically, the patient was stable, with some hypertensive peaks (160/70 mmHg). Bilirubin levels improved, down to 2.19 mg/dl; however, the patient continued to have poor kidney function that required hemodialysis sessions at 6 days after the third surgery. Due to the improvement in respiratory function, extubation was carried out but failed due to weakness in the musculature. For this reason, a tracheostomy was performed at 29 days after admission. Teicoplanin was delivered at 3 days after the third surgery, at 400 mg/12 hours for 6 days by isolation in surgical wound exudate of Enterococcus gallinarum. An infusion of ertapenem and ampicillin at 1 g/24 hours and 1 g/6 hours, respectively, was started at 16 days after the third surgery but was suspended because of a skin rash. Linezolid infusion (600 mg/12 hours) was also started at 20 days after the last intervention in order to treat for Gram-positive bacteria. In the last days of life, the patient showed increased overall deterioration, with disconnection to his environment, oscillation between normothermia and hypothermia, and systolic blood pressure < 70 mmHg, which forced hemodialysis to be suspended. Furthermore, despite hemodialysis, creatinine peaks continued at 8.11 mg/dl, and urea at 190 mg/dl. After receiving palliative care, the patient died, 35 days after admission. No autopsy was requested.", + "fulltext_subclaims": [ + "The patient was a 62-year-old non-Asian Spanish man.", + "He was admitted to the emergency room for abdominal pain of epigastric origin.", + "The pain evolved over the next 3 days to diffuse pain with constipation.", + "He had no fever or vomiting.", + "He had a 32-pack-year smoking history.", + "He had completed disulfiram treatment for alcohol cessation 10 years previously.", + "He was taking naproxen.", + "He had a medical history of a mild factor XII deficiency.", + "On physical examination, palpation showed a contracted abdomen.", + "There were signs of peritonism.", + "Blood pressure was 112/88 mmHg.", + "Heart rate was 122 beats per minute.", + "Temperature was 35.8 ℃.", + "A thoracoabdominal CT scan revealed findings suggestive of intestinal perforation.", + "The CT scan could not clearly identify the point of perforation.", + "Laboratory parameters showed glucose 123 mg/dL.", + "Creatinine was 4.29 mg/dL.", + "Total bilirubin was 1.45 mg/dL.", + "Amylase was 111 mg/dL.", + "Intravenous fluid resuscitation was started.", + "Empiric antimicrobial therapy with piperacillin–tazobactam 3.375 g/8 hours intravenous for 10 days was started.", + "The patient underwent urgent surgical intervention.", + "Surgical intervention revealed generalized peritonitis.", + "The pathology report revealed pyloric wall with signs of perforation.", + "The patient had a low level of consciousness.", + "Oxygen saturation was up to 80%.", + "The patient was intubated.", + "The patient was sedated and on analgesic.", + "The patient was in acute renal failure AKIN III.", + "The patient had anuria.", + "The patient had fecal contamination of the abdominal drainage.", + "A third surgery was performed.", + "The patient underwent partial colectomy.", + "The patient was in stable but serious condition.", + "Bilirubin levels improved, down to 2.19 mg/dl.", + "The patient continued to have poor kidney function.", + "The patient required hemodialysis sessions.", + "A tracheostomy was performed.", + "The patient showed increased overall deterioration.", + "The patient died 35 days after admission." + ], + "summary": "We present an extremely rare case of a 62-year-old Spanish white man patient of non-Asian ethnicity with no history of using natural medications, who was diagnosed with phlebosclerotic colitis of submucosal veins.", + "summary_subclaims": [ + "The patient is a 62-year-old Spanish white man.", + "The patient is of non-Asian ethnicity.", + "The patient has no history of using natural medications.", + "The patient was diagnosed with phlebosclerotic colitis of submucosal veins." + ] + }, + { + "id": "multiclinsum_test_2610_en.txt", + "fulltext": "Herein, we report the case of a 17-month-old male child referred to our Institute presenting gradual onset of mild eyelid ptosis and divergent strabismus of the left eye, preceded two days before by an episode of vomiting. A week prior to the hospitalization, an episode of inconsolable crying, lasting about two hours, occurred with loss of appetite during the following days. Neither fever nor other clinical findings were evident. The patient, third son, was born at term from Cesarean section after pregnancy complicated by placenta previa. Neonatal period was regular. Spherocytosis was diagnosed during the first months of life. His family history revealed spherocytosis (mother and sister) and Hashimoto’s thyroiditis (mother). At admission, physical examination was normal, except for eyelid ptosis and lateral deviation of the left eye due to mild medial rectus muscle deficiency and without pupillary dilation, suggesting the involvement of the third cranial nerve. Fundus examination was normal. C-reacting protein (CRP) was negative. Moreover, serological tests and autoimmune panel were negative. Brain magnetic resonance imaging (MRI), enhanced after contrast administration, and magnetic resonance angiography (MRA) were performed. They suggested a vascular anomaly, along the medial side of the left cerebral peduncle, referable to an arterial aneurysm nearby the ipsilateral third cranial nerve . However, the angio-CT examination did not confirm the vascular anomaly, highlighting a minimal size irregularity of the P1 tract of the left posterior cerebral artery . On the basis of MRI findings, a third cranial nerve neuropathy was suspected. About three weeks after hospital admission, left third oculomotor nerve ophthalmoplegia was no longer appreciable. One month later, a brain MRI was repeated and confirmed a sectorial slight thickening of the emergence of the left third cranial nerve, with a reduced post-contrast enhancement compared with the previous exam .\nOne year later, a brain MRI was repeated, showing a complete resolution of the previous neuroradiological lesions . In relation to MRI findings and clinical situation, the reported case was highly suggestive of an episode of recurrent painful ophthalmoplegic neuropathy. Nonetheless, according to the diagnostic criteria proposed by the International Classification of Headche Disorders (ICHD) (2018) at least two attacks are necessary to confirm the diagnosis . Other considerable, even highly improbable, hypothesis was a schwannoma of the third nerve. For a correct evaluation of the case, we planned a strict follow-up: after 18 months from the diagnosis, the patient had an episode of headache with inconsolable crying treated with paracetamol. During this episode, neurological examination was negative. No other similar episodes with ophtalmoplegia occurred and the neurological examination was negative. After 30 months, the child was conducted at our emergency department presenting again eyelid ptosis and divergent strabismus of the left eye, associated with vomiting and headache. During the hospitalization symptoms gradually resolved spontaneously with a total resolution. This second acute attack confirmed our already strongly suspected diagnosis of RPON.", + "fulltext_subclaims": [ + "The patient was a 17-month-old male child.", + "He presented with gradual onset of mild eyelid ptosis.", + "He had divergent strabismus of the left eye.", + "An episode of vomiting occurred two days before presentation.", + "An episode of inconsolable crying lasting about two hours occurred a week prior to hospitalization.", + "There was loss of appetite during the following days.", + "There was no fever.", + "There were no other clinical findings.", + "The patient was born at term.", + "The birth was via Cesarean section.", + "The pregnancy was complicated by placenta previa.", + "The neonatal period was regular.", + "Spherocytosis was diagnosed during the first months of life.", + "The family history revealed spherocytosis in the mother and sister.", + "The family history revealed Hashimoto’s thyroiditis in the mother.", + "At admission, physical examination was normal except for eyelid ptosis and lateral deviation of the left eye.", + "The lateral deviation was due to mild medial rectus muscle deficiency.", + "There was no pupillary dilation.", + "The findings suggested involvement of the third cranial nerve.", + "Fundus examination was normal.", + "C-reactive protein (CRP) was negative.", + "Serological tests were negative.", + "The autoimmune panel was negative.", + "Brain MRI with contrast and MRA were performed.", + "MRI suggested a vascular anomaly along the medial side of the left cerebral peduncle.", + "The vascular anomaly was referable to an arterial aneurysm nearby the ipsilateral third cranial nerve.", + "Angio-CT did not confirm the vascular anomaly.", + "Angio-CT highlighted a minimal size irregularity of the P1 tract of the left posterior cerebral artery.", + "A third cranial nerve neuropathy was suspected.", + "Three weeks after hospital admission, left third oculomotor nerve ophthalmoplegia was no longer appreciable.", + "One month later, a brain MRI showed sectorial slight thickening of the emergence of the left third cranial nerve.", + "Post-contrast enhancement was reduced compared with the previous exam.", + "One year later, a brain MRI showed complete resolution of the previous neuroradiological lesions.", + "The reported case was highly suggestive of an episode of recurrent painful ophthalmoplegic neuropathy.", + "According to the ICHD (2018), at least two attacks are necessary to confirm the diagnosis.", + "A schwannoma of the third nerve was considered.", + "A strict follow-up was planned.", + "After 18 months from diagnosis, the patient had an episode of headache with inconsolable crying.", + "The episode was treated with paracetamol.", + "Neurological examination during the episode was negative.", + "No other similar episodes with ophthalmoplegia occurred.", + "After 30 months, the child presented again with eyelid ptosis and divergent strabismus of the left eye.", + "The second episode was associated with vomiting and headache.", + "Symptoms gradually resolved spontaneously.", + "There was total resolution of symptoms.", + "The second acute attack confirmed the diagnosis of RPON." + ], + "summary": "The authors present a case of third cranial nerve paresis in a 17-month-old male child, presenting a neuroradiological pattern highly suggestive of schwannoma, aneurism or recurrent painful ophthalmoplegic neuropathy. Thus, a review of the literature with the pediatric casuistry of recurrent painful ophthalmoplegic neuropathy occurred within 2 years of age focusing on diagnostic considerations is presented. The authors highlight the importance to consider recurrent painful ophthalmoplegic neuropathy in presence of magnetic resonance imaging findings and clinical symptoms referable to aneurysm or schwannoma. Thus, the review defines the characteristics and the neuroradiological findings at the first RPON attack occurred under 2 years of age.", + "summary_subclaims": [ + "The authors present a case of third cranial nerve paresis in a 17-month-old male child.", + "The neuroradiological pattern is highly suggestive of schwannoma, aneurism or recurrent painful ophthalmoplegic neuropathy.", + "A review of the literature with the pediatric casuistry of recurrent painful ophthalmoplegic neuropathy occurred within 2 years of age is presented.", + "The authors highlight the importance to consider recurrent painful ophthalmoplegic neuropathy in presence of magnetic resonance imaging findings and clinical symptoms referable to aneurysm or schwannoma.", + "The review defines the characteristics and the neuroradiological findings at the first RPON attack occurred under 2 years of age." + ] + }, + { + "id": "multiclinsum_test_724_en.txt", + "fulltext": "A 60-year-old male patient diagnosed with non-ischemic dilated cardiomyopathy with reduced LVEF and LBBB was referred to our clinic for progressive exertional dyspnea and fatigue symptoms developed over the previous two years. The patient was in functional NYHA class II despite maximally tolerated doses of angiotensin receptor-neprilysin inhibitors, beta-blockers, mineralocorticoid receptor antagonists, and sodium-glucose cotransporter-2 inhibitors for the past six months. The presenting ECG showed sinus rhythm with an LBBB morphology and a QRS duration of 160 ms . Echocardiography revealed an enlarged left ventricle (LV) with an ejection fraction of 26%, normal wall thickness, overt signs of intraventricular dyssynchrony (apical rocking and septal flash), moderate mitral regurgitation, biatrial enlargement, and non-dilated right ventricle. The lab results were unremarkable. Given the clinical, electrocardiographic, and echocardiographic findings, the patient had a class I recommendation for CRT. Our laboratory has adopted CSP as the first option for patients with CRT indications for the past two years. For this case with potentially difficult anatomy (dilated LV and atria possibly displacing and modifying the trajectory of the conduction system), we decided to perform the procedure guided by a 3D mapping system, the Ensite Precision system (Abbott Cardiovascular, Plymouth, MN, USA), to reduce the X-ray exposure. After obtaining two separate entry sites in the axillary vein, a conventional atrial lead was placed at the right ventricular apex and connected to the 3D system to serve as a reference and backup pacing. Using the other axillary route, a deflectable decapolar EP catheter was used to create the anatomy of the right atrium, the coronary sinus, and the basal part of the right ventricle. After delineating the tricuspid valve, we thoroughly mapped and tagged the His bundle (HB) cloud from proximal to distal (a). With the map completed, the EP catheter was withdrawn, and a deflectable Medtronic C304 His catheter (Medtronic Inc., Minneapolis, MN, USA) with a Medtronic SelectSecure 3830 lead (Medtronic Inc., Minneapolis, MN, USA) inside was introduced. The lead was connected in a unipolar fashion to the 3D system so that the tip of the lead would be visible on the map (a). The catheter was placed at the distal part of the HB cloud (b), where repeated pacing showed complete correction of the LBBB, but unfortunately, at unacceptably high thresholds (3 V at 1ms pulse duration) (c). In the next step, a point was marked on the 3D map at 1.5 cm from the distal His location towards the right ventricular apex (d). The catheter was placed at that spot, and the lead was screwed deep into the septum under minimal fluoroscopic guidance until fixation beats with right bundle branch block morphology were observed (a,b). Pacing at that site revealed a narrow QRS complex with a QR morphology in lead V1, a duration of 125 ms, and an LVAT of 70 ms (c). Differential pacing with two extra stimuli showed an evident change in the morphology of the premature complex, proving the initial capture of more than one structure and, implicitly, the LBB capture (d). The catheter was retracted and slit, followed by atrial lead placement in the right atrial appendage under fluoroscopy. The procedural pacing threshold was 0.75 V at 0.4 ms pulse duration with a detection of 12 mV and a fluoroscopy time of 2 min. The total procedural time was 120 min, with 17 min dedicated to 3D mapping. The final electrocardiography showed atrial synchronized, narrow-paced QRS complexes with different degrees of fusion . There were no periprocedural complications, and the patient was discharged uneventfully the next day. The pacing and sensing thresholds were stable over the follow-up period. The 3-month echocardiography follow-up revealed a significant increase in LVEF (from 26% to 43%) and a decrease in left ventricular volumes (the end-systolic volume decreased from 174 mL to 132 mL). The patient also had a substantial clinical improvement with no heart failure symptoms during normal daily activities.", + "fulltext_subclaims": [ + "The patient was a 60-year-old male.", + "The patient had non-ischemic dilated cardiomyopathy with reduced LVEF.", + "The patient had LBBB.", + "The patient had progressive exertional dyspnea and fatigue symptoms developed over the previous two years.", + "The patient was in functional NYHA class II.", + "The patient was on maximally tolerated doses of angiotensin receptor-neprilysin inhibitors, beta-blockers, mineralocorticoid receptor antagonists, and sodium-glucose cotransporter-2 inhibitors.", + "The presenting ECG showed sinus rhythm with an LBBB morphology.", + "The QRS duration was 160 ms.", + "Echocardiography revealed an enlarged left ventricle.", + "Echocardiography showed an ejection fraction of 26%.", + "Echocardiography showed overt signs of intraventricular dyssynchrony.", + "Echocardiography showed moderate mitral regurgitation.", + "Echocardiography showed biatrial enlargement.", + "The lab results were unremarkable.", + "The patient had a class I recommendation for CRT.", + "The procedure was guided by a 3D mapping system.", + "The Ensite Precision system was used.", + "A conventional atrial lead was placed at the right ventricular apex.", + "A deflectable decapolar EP catheter was used to create the anatomy of the right atrium, the coronary sinus, and the basal part of the right ventricle.", + "The His bundle cloud was mapped from proximal to distal.", + "The lead was connected in a unipolar fashion to the 3D system.", + "The catheter was placed at the distal part of the HB cloud.", + "Pacing at that site revealed a narrow QRS complex with a QR morphology in lead V1.", + "The QRS duration was 125 ms.", + "The LVAT was 70 ms.", + "Differential pacing with two extra stimuli showed an evident change in the morphology of the premature complex.", + "The procedural pacing threshold was 0.75 V at 0.4 ms pulse duration.", + "The fluoroscopy time was 2 min.", + "The total procedural time was 120 min.", + "The 3-month echocardiography follow-up revealed a significant increase in LVEF from 26% to 43%.", + "The 3-month echocardiography follow-up showed a decrease in left ventricular volumes.", + "The end-systolic volume decreased from 174 mL to 132 mL.", + "The patient had a substantial clinical improvement with no heart failure symptoms during normal daily activities." + ], + "summary": "We present the case of a 60-year-old patient with non-ischemic dilated cardiomyopathy and left bundle branch block in whom conduction system pacing was chosen as the first option for resynchronization therapy. A 3D electro-anatomical mapping system was used to guide the lead to the His bundle region, where correction was observed at high amplitudes, and afterward to the optimal septal penetration site. After reaching the left endocardium, left bundle branch pacing achieved a narrow, paced QRS complex with low fluoroscopy exposure. The three-month follow-up showed a significant improvement in clinical status and left ventricular function.", + "summary_subclaims": [ + "The patient was a 60-year-old individual.", + "The patient had non-ischemic dilated cardiomyopathy.", + "The patient had left bundle branch block.", + "Conduction system pacing was chosen as the first option for resynchronization therapy.", + "A 3D electro-anatomical mapping system was used to guide the lead.", + "The lead was guided to the His bundle region.", + "Correction was observed at high amplitudes.", + "The lead was guided to the optimal septal penetration site.", + "After reaching the left endocardium, left bundle branch pacing was performed.", + "A narrow, paced QRS complex was achieved.", + "Low fluoroscopy exposure was achieved.", + "The three-month follow-up showed significant improvement in clinical status.", + "The three-month follow-up showed significant improvement in left ventricular function." + ] + }, + { + "id": "multiclinsum_test_2060_en.txt", + "fulltext": "A 34-year-old female with recurrent ischaemic stroke, type 1 diabetes mellitus, hypertension, dyslipidaemia and stage 2 chronic kidney disease, presented to the outpatient stroke clinic in June 2020 with a history of recurrent transitory right leg weakness and right hand shaking. These episodes occurred several times per day lasting approximately 30 s whilst mobilising and resolved on sitting. Neurological examination demonstrated recovering dysphasia and mild pyramidal right-sided weakness requiring a walking stick for gait assistance.\nPreviously, in March 2019, she presented with slurred speech, left-sided weakness and visual neglect with confirmed bilateral embolic middle cerebral artery (MCA) territory infarcts on magnetic resonance imaging (MRI). Computer tomography (CT) carotid angiography and Digital subtraction angiogram (DSA) identified severe ICAD with bilateral occlusion of the supraclinoid segment of the internal carotid arteries but no features of moyamoya disease . She had no family history of stroke, a negative thrombophilia screen and no cardioembolic source identified. Secondary prevention was commenced including aggressive lipid lowering with rosuvastatin aiming for low density lipoprotein < 1.8 mmol/L, dual antiplatelet therapy with aspirin and clopidogrel for three months, antihypertensive treatment aiming for blood pressure < 130/80 mmHg and augmentation of her diabetic regime. She recovered to a point of supported independent living but was unable to return to work.\nIn March 2020 she represented to the emergency department with reduced consciousness in a state of diabetic ketoacidosis secondary to a lower respiratory tract infection and episodes of vomiting. On presentation her blood pressure was 70/40 mmHg and she was found to have new right-sided weakness. Diffusion weighted MRI identified multiple acute embolic infarcts in the left MCA territory. Her deficits improved with a period of neurorehabilitation but she had ongoing high-level language and cognitive difficulties, marked post stroke fatigue as well as reduced high-level balance. She was independent in personal care.\nIn neurorehabilitation initial concerns were for post stroke focal motor seizures causing her transient symptoms and she was commenced on levetiracetam. However, these brief episodes spared the face, did not exhibit Jacksonian march and were precipitated by periods of reduced cerebral perfusion such as changing position and dehydration. When reviewed in stroke clinic the leading differential diagnosis was cerebral hypoperfusion syndrome. A 99mTc-ethyl cysteine dimer cerebral perfusion single photon emission CT (SPECT) with CT acetazolamide challenge was performed . Baseline perfusion was reduced in the left frontal, temporal and parietal lobes in keeping with recent infarction as well as a small fixed perfusion defect in the right frontal lobe corresponding to previous established infarct. Although asymptomatic during scanning, worsening hypoperfusion to the left frontal lobe and to a lesser extent the left temporal and anterior parietal lobes, was evident with acetazolamide challenge, indicative of reduced vascular reserve in these territories. Given her ongoing symptoms and declining quality of life a repeat DSA was performed to assess for possible sites of surgical revascularisation. The second DSA demonstrated progressive intracranial stenosis with opacification of the left posterior communicating artery and collateral supply to the left hemisphere predominantly from the posterior choroidal artery and posterior cerebral artery . No feasible site for surgical revascularisation was identified. She was managed on maximal medical therapy including long term dual antiplatelet therapy, consolidated antihypertensive regime, tight glycaemic control and avoidance of dehydration. Over the following six months a systolic blood pressure between 120 and 130/70 mmHg was achieved, with a low-density lipoprotein of 1.0 mmol/L and high-density lipoprotein of 1.2 mmol/L. Glycaemic control remained an ongoing challenge, with a glycosylated haemoglobin level of 9.5% (80 mmol/mol). The patient has recently trialled a continuous infusion pump device. Levetiracetam was ceased. During this period the limb-shaking TIAs settled.", + "fulltext_subclaims": [ + "The patient is a 34-year-old female.", + "She has a history of recurrent ischaemic stroke.", + "She has type 1 diabetes mellitus.", + "She has hypertension.", + "She has dyslipidaemia.", + "She has stage 2 chronic kidney disease.", + "She presented to the outpatient stroke clinic in June 2020.", + "She had transitory right leg weakness.", + "She had right hand shaking.", + "These episodes occurred several times per day.", + "The episodes lasted approximately 30 seconds.", + "The episodes occurred while mobilising.", + "The episodes resolved on sitting.", + "Neurological examination demonstrated recovering dysphasia.", + "Neurological examination demonstrated mild pyramidal right-sided weakness.", + "She required a walking stick for gait assistance.", + "In March 2019, she presented with slurred speech.", + "In March 2019, she had left-sided weakness.", + "In March 2019, she had visual neglect.", + "MRI confirmed bilateral embolic middle cerebral artery territory infarcts.", + "CT carotid angiography identified severe ICAD.", + "DSA identified bilateral occlusion of the supraclinoid segment of the internal carotid arteries.", + "There were no features of moyamoya disease.", + "She had no family history of stroke.", + "She had a negative thrombophilia screen.", + "No cardioembolic source was identified.", + "Secondary prevention included aggressive lipid lowering with rosuvastatin.", + "The target low density lipoprotein was < 1.8 mmol/L.", + "Dual antiplatelet therapy with aspirin and clopidogrel was commenced for three months.", + "Antihypertensive treatment aimed for blood pressure < 130/80 mmHg.", + "Her diabetic regime was augmented.", + "She recovered to a point of supported independent living.", + "She was unable to return to work.", + "In March 2020, she presented with reduced consciousness.", + "The cause was diabetic ketoacidosis secondary to a lower respiratory tract infection.", + "On presentation, her blood pressure was 70/40 mmHg.", + "She had new right-sided weakness.", + "Diffusion weighted MRI identified multiple acute embolic infarcts in the left MCA territory.", + "Her deficits improved with neurorehabilitation.", + "She had ongoing high-level language and cognitive difficulties.", + "She had marked post stroke fatigue.", + "She had reduced high-level balance.", + "She was independent in personal care.", + "Initial concerns were for post stroke focal motor seizures.", + "She was commenced on levetiracetam.", + "The brief episodes spared the face.", + "The brief episodes did not exhibit Jacksonian march.", + "The brief episodes were precipitated by periods of reduced cerebral perfusion.", + "The leading differential diagnosis was cerebral hypoperfusion syndrome.", + "A 99mTc-ethyl cysteine dimer cerebral perfusion SPECT with CT acetazolamide challenge was performed.", + "Baseline perfusion was reduced in the left frontal, temporal, and parietal lobes.", + "Baseline perfusion was in keeping with recent infarction.", + "A small fixed perfusion defect was in the right frontal lobe.", + "The fixed perfusion defect corresponded to previous established infarct.", + "Worsening hypoperfusion to the left frontal lobe was evident with acetazolamide challenge.", + "Worsening hypoperfusion to the left temporal and anterior parietal lobes was evident with acetazolamide challenge.", + "This indicated reduced vascular reserve in these territories.", + "A repeat DSA was performed to assess for possible sites of surgical revascularisation.", + "The second DSA demonstrated progressive intracranial stenosis.", + "The left posterior communicating artery was opacified.", + "Collateral supply to the left hemisphere was from the posterior choroidal artery and posterior cerebral artery.", + "No feasible site for surgical revascularisation was identified.", + "She was managed on maximal medical therapy.", + "Long term dual antiplatelet therapy was continued.", + "A consolidated antihypertensive regime was continued.", + "Tight glycaemic control was continued.", + "Avoidance of dehydration was recommended.", + "A systolic blood pressure between 120 and 130/70 mmHg was achieved.", + "A low-density lipoprotein of 1.0 mmol/L was achieved.", + "A high-density lipoprotein of 1.2 mmol/L was achieved.", + "Glycaemic control remained an ongoing challenge.", + "A glycosylated haemoglobin level of 9.5% (80 mmol/mol) was recorded.", + "She recently trialled a continuous infusion pump device.", + "Levetiracetam was ceased.", + "During this period, the limb-shaking TIAs settled." + ], + "summary": "We present the case of a young female who developed limb-shaking TIA in the context of progressive severe intracranial atherosclerotic disease (ICAD). Previous cortical infarction raised suspicion for seizure as a cause of her symptoms. However, single photon emission CT (SPECT) with CT acetazolamide challenge identified severe left hemisphere cerebral hypoperfusion and a diagnosis of limb-shaking TIA was made. Symptoms improved with maximal medical management.", + "summary_subclaims": [ + "The patient is a young female.", + "The patient developed limb-shaking TIA.", + "The patient had progressive severe intracranial atherosclerotic disease.", + "The patient had a previous cortical infarction.", + "Single photon emission CT with CT acetazolamide challenge identified severe left hemisphere cerebral hypoperfusion.", + "A diagnosis of limb-shaking TIA was made.", + "Symptoms improved with maximal medical management." + ] + }, + { + "id": "multiclinsum_test_2183_en.txt", + "fulltext": "A 55-year-old man was admitted to a provincial hospital with fecal occult blood. Colonoscopy revealed a submucosal tumor with depression in the anterior wall of the distal rectum . The tumor was diagnosed as a rectal NET following pathological examination of the biopsy specimen, and he was referred to our hospital for further examination. Endorectal endoscopic ultrasound revealed a 14-mm oval tumor with deep invasion to the submucosa layer. The tumor was located at 1.8 cm from the anal verge. Systematic computed tomography (CT) revealed no evidence of regional lymph node metastasis or distant metastasis such as that to the liver or lung. On the basis of these findings, we performed laparoscopic subtotal and D2 lymph node dissection with diverting stoma. The macroscopic finding of the resected specimen revealed an oval-shaped tumor with depression. Pathological examination with hematoxylin and eosin (HE) staining showed the tumor cells spreading in a rosette-like pattern. Immunohistochemical staining revealed the tumor cells to be positive for chromogranin A and synaptophysin, with a Ki-67 labeling index of 3% . Pathological diagnosis was NET of the rectum, G2, T1b (invasion to submucosa), N0, Stage I without lymphovascular invasion. Diverting stoma closure was performed 6 months after the initial operation. A follow-up abdominopelvic CT scan at 12 months after surgery detected a 4-mm mass in the left internal iliac region . The mass was followed with abdominopelvic CT every 6 months and occasional positron emission tomography (PET)-CT. At 54 months after surgery, the mass had enlarged to 20 mm , but PET-CT did not show abnormal uptake in the tumor or in other distant organs. Because the mass had enlarged over time, we suspected it to be a single lateral lymph node recurrence, and we performed left lateral lymph node dissection. The resected specimen was again an oval-shaped mass of 14 mm in size . The finding from HE staining was similar to that in the specimen resected at the primary surgery . Immunohistochemical staining again revealed the same findings as in the previous resected specimen, i.e., cells positive for chromogranin A and synaptophysin positive, but now the Ki-67 labeling index had increased slightly to 5% . On the basis of these findings, the pathological diagnosis was lateral lymph node recurrence. The patient was followed up with CT every 6 months and colonoscopy annually. At 42 months after the second surgery, the patient has shown no evidence of recurrence.", + "fulltext_subclaims": [ + "The patient was a 55-year-old man.", + "He was admitted to a provincial hospital with fecal occult blood.", + "Colonoscopy revealed a submucosal tumor with depression in the anterior wall of the distal rectum.", + "The tumor was diagnosed as a rectal NET following pathological examination of the biopsy specimen.", + "He was referred to our hospital for further examination.", + "Endorectal endoscopic ultrasound revealed a 14-mm oval tumor with deep invasion to the submucosa layer.", + "The tumor was located at 1.8 cm from the anal verge.", + "Systematic computed tomography (CT) revealed no evidence of regional lymph node metastasis.", + "Systematic CT revealed no evidence of distant metastasis such as that to the liver or lung.", + "We performed laparoscopic subtotal and D2 lymph node dissection with diverting stoma.", + "The macroscopic finding of the resected specimen revealed an oval-shaped tumor with depression.", + "Pathological examination with hematoxylin and eosin (HE) staining showed the tumor cells spreading in a rosette-like pattern.", + "Immunohistochemical staining revealed the tumor cells to be positive for chromogranin A.", + "Immunohistochemical staining revealed the tumor cells to be positive for synaptophysin.", + "The Ki-67 labeling index was 3%.", + "Pathological diagnosis was NET of the rectum, G2, T1b (invasion to submucosa), N0, Stage I without lymphovascular invasion.", + "Diverting stoma closure was performed 6 months after the initial operation.", + "A follow-up abdominopelvic CT scan at 12 months after surgery detected a 4-mm mass in the left internal iliac region.", + "The mass was followed with abdominopelvic CT every 6 months.", + "PET-CT was performed occasionally.", + "At 54 months after surgery, the mass had enlarged to 20 mm.", + "PET-CT did not show abnormal uptake in the tumor.", + "PET-CT did not show abnormal uptake in other distant organs.", + "We suspected the mass to be a single lateral lymph node recurrence.", + "We performed left lateral lymph node dissection.", + "The resected specimen was again an oval-shaped mass of 14 mm in size.", + "The finding from HE staining was similar to that in the specimen resected at the primary surgery.", + "Immunohistochemical staining again revealed the same findings as in the previous resected specimen.", + "The Ki-67 labeling index had increased slightly to 5%.", + "The pathological diagnosis was lateral lymph node recurrence.", + "The patient was followed up with CT every 6 months.", + "The patient was followed up with colonoscopy annually.", + "At 42 months after the second surgery, the patient has shown no evidence of recurrence." + ], + "summary": "A 55-year-old man presented with fecal occult blood and colonoscopy revealed a mass in the distal rectum. Systematic computed tomography scan showed no evidence of regional lymph node or distant metastasis. The patient underwent laparoscopic intersphincteric resection and D2 lymph node dissection with diverting stoma. Diverting stoma closure was performed 6 months after the initial operation. Pathological diagnosis was NET of the rectum, grade 2, T1b, N0, Stage I without lymphovascular invasion. At 54 months after the surgery, recurrence in a left lateral lymph node was suspected and lymph node dissection was performed. The pathological diagnosis of the specimen was consistent with lateral lymph node metastasis of a recurrent rectal NET. To our best knowledge, there are no case reports in English of lateral lymph node recurrence after curative resection of a rectal NET, grade 2, T1b, N0, Stage I without lymphovascular invasion.", + "summary_subclaims": [ + "A 55-year-old man presented with fecal occult blood.", + "Colonoscopy revealed a mass in the distal rectum.", + "Systematic computed tomography scan showed no evidence of regional lymph node or distant metastasis.", + "The patient underwent laparoscopic intersphincteric resection and D2 lymph node dissection with diverting stoma.", + "Diverting stoma closure was performed 6 months after the initial operation.", + "Pathological diagnosis was NET of the rectum, grade 2, T1b, N0, Stage I without lymphovascular invasion.", + "At 54 months after the surgery, recurrence in a left lateral lymph node was suspected.", + "Lymph node dissection was performed.", + "The pathological diagnosis of the specimen was consistent with lateral lymph node metastasis of a recurrent rectal NET.", + "To our best knowledge, there are no case reports in English of lateral lymph node recurrence after curative resection of a rectal NET, grade 2, T1b, N0, Stage I without lymphovascular invasion." + ] + }, + { + "id": "multiclinsum_test_3209_en.txt", + "fulltext": "5-year-old girl with no relevant perinatal history, who presented with slurred speech and gait instability, with a paternal history of a diagnosis of HD, as well as three uncles and her grandmother, all from the paternal branch, with some degree of motor disability or psychiatric disorder. She had normal development until the age of 3, when she began to regress in previously acquired language patterns. At the age of 5, she added a motor disorder with frequent falls and dystonic gait, which is why she was referred. The condition progressed gradually and at the time of the evaluation she was dependent on almost all activities of daily living. Her language skills were below what was expected for her age in terms of expressive aspects (slurred speech). Her comprehension was also affected, although it improved with visual supports. She had a communicative intention and good eye contact, which showed reciprocity in her communicative abilities and interest in peers, using non-verbal resources such as pointing and gestures, sometimes accompanied by words. There was also difficulty in gait secondary to dystonia with frequent falls. She associated sporadic choreic movements of the upper limbs, with a low frequency of occurrence. There was evidence of drooling and a lack of oral closure, and slow and poorly coordinated oral movements. Her behaviour was usually calm, but she presented sporadic episodes of irritability in response to frustrating situations.\n\nWithin the complementary studies requested, the magnetic resonance of the brain showed atrophy of the caudate and lenticular nuclei in a symmetrical way, and the electroencephalographic study was normal. The molecular study (expansion of triplets CAG) showed 51 ± 1 repetitions of the triplet CAG in the locus 4p16.3, which confirmed the diagnosis and showed a phenomenon of anticipation by the early appearance of the disease in the patient.\n\nThe family was advised on the use of alternative-augmentative communication systems to promote communication and behavior. Phonoaudiological and kinesthetic treatment was indicated in their area of residence, and continued in the regular school with a support for inclusion modality.\n", + "fulltext_subclaims": [ + "The patient is a 5-year-old girl.", + "She had no relevant perinatal history.", + "She presented with slurred speech.", + "She presented with gait instability.", + "There is a paternal history of a diagnosis of HD.", + "Three uncles and her grandmother, all from the paternal branch, had some degree of motor disability or psychiatric disorder.", + "She had normal development until the age of 3.", + "At the age of 3, she began to regress in previously acquired language patterns.", + "At the age of 5, she added a motor disorder with frequent falls and dystonic gait.", + "The condition progressed gradually.", + "At the time of the evaluation, she was dependent on almost all activities of daily living.", + "Her language skills were below what was expected for her age in terms of expressive aspects.", + "Her comprehension was also affected.", + "Her comprehension improved with visual supports.", + "She had a communicative intention.", + "She had good eye contact.", + "She showed reciprocity in her communicative abilities.", + "She showed interest in peers.", + "She used non-verbal resources such as pointing and gestures.", + "She sometimes used words with non-verbal resources.", + "There was difficulty in gait secondary to dystonia with frequent falls.", + "She had sporadic choreic movements of the upper limbs.", + "The choreic movements had a low frequency of occurrence.", + "There was evidence of drooling.", + "There was a lack of oral closure.", + "There were slow and poorly coordinated oral movements.", + "Her behaviour was usually calm.", + "She presented sporadic episodes of irritability in response to frustrating situations.", + "The magnetic resonance of the brain showed atrophy of the caudate and lenticular nuclei in a symmetrical way.", + "The electroencephalographic study was normal.", + "The molecular study showed 51 ± 1 repetitions of the triplet CAG in the locus 4p16.3.", + "The molecular study confirmed the diagnosis.", + "The molecular study showed a phenomenon of anticipation by the early appearance of the disease in the patient.", + "The family was advised on the use of alternative-augmentative communication systems.", + "Phonoaudiological and kinesthetic treatment was indicated in their area of residence.", + "The treatment continued in the regular school with a support for inclusion modality." + ], + "summary": "5-year-old girl with a family history of HD and typical development until 3 years of age. She progressively presented language impairment with decreased age-appropriate expressive and receptive language skills, without impairment of pragmatic and social skills. Motor skills, gait and standing were unstable, and she showed rigidity, dystonia and choreic movements. She presented atrophy of the lenticular and caudate nuclei in the MRI, and later molecular diagnosis was performed with the expansion of CAG triplets (51 copies).\n", + "summary_subclaims": [ + "The patient is a 5-year-old girl.", + "The patient has a family history of HD.", + "The patient had typical development until 3 years of age.", + "The patient progressively presented language impairment.", + "The patient had decreased age-appropriate expressive and receptive language skills.", + "The patient did not have impairment of pragmatic and social skills.", + "The patient had unstable motor skills, gait, and standing.", + "The patient showed rigidity, dystonia, and choreic movements.", + "The patient presented atrophy of the lenticular and caudate nuclei in the MRI.", + "The patient later had a molecular diagnosis performed.", + "The molecular diagnosis showed expansion of CAG triplets (51 copies)." + ] + }, + { + "id": "multiclinsum_test_1762_en.txt", + "fulltext": "A 29-year-old African-American male with a past medical history of advanced AIDS and non-compliance with medications was presented with acute onset of chest pain. The pain was associated with shortness of breath. Physical activity worsened the intensity of the pain. He denied any nausea, vomiting or diaphoresis. Physical examination was unremarkable. Laboratory work up on admission showed a troponin T level of 5.0 ng/ml (upper limit of normal = 0.10 ng/ml), white blood cell (WBC) count of 2.0 K/uL and eosinophil count 1.52 K/uL (upper limit of normal = 0.4 k/uL), hemoglobin level of 9 g/dL and platelets count of 250,000/μL and absolute CD4 count of 12/mm3. Renal, liver and clotting profiles were all normal. The electrocardiogram (EKG) initially showed T wave inversions in the anterior leads, which were not present on prior EKGs. The troponin T level rose to a peak of 35.8 ng/ml and a repeat EKG revealed changes consistent with inferior wall myocardial ischemia. The 2D echocardiogram revealed decreased ejection fraction estimated at 30–35% with no wall motion abnormalities. Workup for hypercoagulable state including anticardiolipin antibodies, protein C, protein S, factor V Leiden and homocysteine levels tests were all negative.\nOf interest, throughout the year prior to admission, the percentage of eosinophil was noted to be persistently and abnormally high. In that same period, the patient was leukopenic with WBC count ranging between 0.8 K/ul and 3 K/ul. In addition, Immunoglobulin E level was found to be elevated at 9330 IU/ml (normal <100 IU/ml). Fluorescence in situ Hybridization (FISH) peripheral blood analysis was negative for FIP1L1-PDGFRB translocation. Bone marrow biopsy showed slightly hypercellular tri-lineage hematopoiesis with no evidence of any pathological/clonal hematologic disorder. The anti-neutrophil cytoplasm antibodies (ANCA), anti-nuclear antibodies (ANA), rheumatoid factor, myeloperoxidase antibody, proteinase 3 antibody, anti-cyclic citrullinated peptides (CCP) were negative. Serologic studies for infection, hepatitis, toxoplasmosis, autoimmune, and paraneoplastic disease were negative. Stool analysis and blood films were negative for parasites.\nOn the basis of his elevated troponins and echocardiographic findings, he was initially managed for non-ST elevation myocardial infarction (NSTEMI) with aspirin, statin, clopidogrel, beta blockers and heparin. Angiography showed that our patient had a mild non-obstructive disease. A cardiac magnetic resonance imaging (CMR) was done [Figures and ] and it showed a pattern typical of eosinophilic endomyocarditis. He was started on daily methylprednisolone 1 mg/kg intravenously. On steroid treatment, the eosinophilic count decreased dramatically and his clinical state ameliorated rapidly. A repeat echocardiogram on day 10 revealed an increase in ejection fraction and systolic function confirming the therapeutic benefit of the steroid therapy.", + "fulltext_subclaims": [ + "The patient is a 29-year-old African-American male.", + "The patient has a past medical history of advanced AIDS.", + "The patient had non-compliance with medications.", + "The patient presented with acute onset of chest pain.", + "The chest pain was associated with shortness of breath.", + "Physical activity worsened the intensity of the pain.", + "The patient denied any nausea, vomiting or diaphoresis.", + "Physical examination was unremarkable.", + "On admission, the troponin T level was 5.0 ng/ml.", + "The upper limit of normal for troponin T is 0.10 ng/ml.", + "The white blood cell count was 2.0 K/uL.", + "The eosinophil count was 1.52 K/uL.", + "The upper limit of normal for eosinophil count is 0.4 k/uL.", + "The hemoglobin level was 9 g/dL.", + "The platelets count was 250,000/μL.", + "The absolute CD4 count was 12/mm3.", + "The electrocardiogram initially showed T wave inversions in the anterior leads.", + "The troponin T level rose to a peak of 35.8 ng/ml.", + "The repeat EKG revealed changes consistent with inferior wall myocardial ischemia.", + "The 2D echocardiogram revealed decreased ejection fraction estimated at 30–35%.", + "The 2D echocardiogram showed no wall motion abnormalities.", + "The workup for hypercoagulable state was negative.", + "The patient had persistently and abnormally high eosinophil percentage throughout the year prior to admission.", + "The patient was leukopenic with WBC count ranging between 0.8 K/ul and 3 K/ul.", + "The Immunoglobulin E level was 9330 IU/ml.", + "The normal range for Immunoglobulin E is <100 IU/ml.", + "FISH peripheral blood analysis was negative for FIP1L1-PDGFRB translocation.", + "Bone marrow biopsy showed slightly hypercellular tri-lineage hematopoiesis.", + "The bone marrow biopsy showed no evidence of any pathological/clonal hematologic disorder.", + "The anti-neutrophil cytoplasm antibodies were negative.", + "The anti-nuclear antibodies were negative.", + "The rheumatoid factor was negative.", + "The myeloperoxidase antibody was negative.", + "The proteinase 3 antibody was negative.", + "The anti-cyclic citrullinated peptides were negative.", + "Serologic studies for infection, hepatitis, toxoplasmosis, autoimmune, and paraneoplastic disease were negative.", + "Stool analysis was negative for parasites.", + "Blood films were negative for parasites.", + "The patient was initially managed for non-ST elevation myocardial infarction.", + "Angiography showed mild non-obstructive disease.", + "The cardiac magnetic resonance imaging showed a pattern typical of eosinophilic endomyocarditis.", + "The patient was started on daily methylprednisolone 1 mg/kg intravenously.", + "The eosinophilic count decreased dramatically on steroid treatment.", + "The patient's clinical state ameliorated rapidly on steroid treatment.", + "A repeat echocardiogram on day 10 revealed an increase in ejection fraction.", + "The repeat echocardiogram confirmed the therapeutic benefit of the steroid therapy." + ], + "summary": "We report a case of a 29-year-old patient with Acquired Immunodeficiency Syndrome (AIDS) who had a persistent elevation of eosinophil counts and elevated IgE levels for a year prior to admission. He was presented to our emergency department with chest pain and laboratory tests revealed peripheral blood eosinophilia and elevated troponins. Coronary angiogram showed nonobstructive coronary artery disease. He then underwent cardiac magnetic resonance imaging which was consistent with an infiltrative myocarditis. After being put on steroid therapy, his peripheral eosinophilia resolved and his cardiac symptoms improved.", + "summary_subclaims": [ + "The patient was a 29-year-old man with Acquired Immunodeficiency Syndrome.", + "He had a persistent elevation of eosinophil counts for a year prior to admission.", + "He had elevated IgE levels for a year prior to admission.", + "He was presented to the emergency department with chest pain.", + "Laboratory tests revealed peripheral blood eosinophilia.", + "Laboratory tests revealed elevated troponins.", + "Coronary angiogram showed nonobstructive coronary artery disease.", + "He underwent cardiac magnetic resonance imaging.", + "The cardiac magnetic resonance imaging was consistent with infiltrative myocarditis.", + "After being put on steroid therapy, his peripheral eosinophilia resolved.", + "After being put on steroid therapy, his cardiac symptoms improved." + ] + }, + { + "id": "multiclinsum_test_548_en.txt", + "fulltext": "The patient was a 78-year-old woman who first presented with a mild decrease in cognitive function at the age of 75 years. She did not exhibit signs of neurological deficits such as anisocoria or diplopia. However, magnetic resonance imaging revealed a left-sided ICA-PcomA aneurysm. Three-dimensional computed tomography (CT) angiography revealed an irregularly shaped aneurysm measuring 7 mm . We limited treatment to follow-up observations of the aneurysm in the outpatient department without surgery, considering her age and deteriorated cognitive function. She had not experienced any episodes of oculomotor nerve palsy or sudden thunderclap headaches. The aneurysm gradually grew to 10 mm in size by the time she was 78 years old . We planned to clip the neck of the aneurysm to firmly preserve the fetal-type PcomA, which seemed to arise from the aneurysmal body, due to an increased risk of rupture . We performed a pterional craniotomy and approached the aneurysm through the transsylvian route. The aneurysm had adhered strongly to the oculomotor nerve and surrounding tissue. We clipped the neck of the aneurysm [ and ] followed by careful separation of the aneurysmal wall and inspection of the oculomotor nerve. We observed that the dome of the aneurysm was splitting the oculomotor nerve [ and ] . Temporary anisocoria and diplopia were observed postoperatively. These oculomotor nerve palsy symptoms improved in approximately 10 days. The patient was discharged with a Modified Rankin Scale score of 1.\nThe patient provided written informed consent for the publication of this report.", + "fulltext_subclaims": [ + "The patient was a 78-year-old woman.", + "She first presented with a mild decrease in cognitive function at the age of 75 years.", + "She did not exhibit signs of neurological deficits such as anisocoria or diplopia.", + "Magnetic resonance imaging revealed a left-sided ICA-PcomA aneurysm.", + "Three-dimensional computed tomography angiography revealed an irregularly shaped aneurysm measuring 7 mm.", + "We limited treatment to follow-up observations of the aneurysm in the outpatient department without surgery.", + "She had not experienced any episodes of oculomotor nerve palsy.", + "The aneurysm gradually grew to 10 mm in size by the time she was 78 years old.", + "We planned to clip the neck of the aneurysm to firmly preserve the fetal-type PcomA.", + "We performed a pterional craniotomy.", + "The aneurysm had adhered strongly to the oculomotor nerve and surrounding tissue.", + "We clipped the neck of the aneurysm.", + "Temporary anisocoria and diplopia were observed postoperatively.", + "These oculomotor nerve palsy symptoms improved in approximately 10 days.", + "The patient was discharged with a Modified Rankin Scale score of 1." + ], + "summary": "We present the rare case of an asymptomatic, growing, left-sided ICA-PcomA aneurysm that was confirmed to split the oculomotor nerve. We report the clinical course and discuss the underlying mechanism. The oculomotor nerve, which is an aggregate of multiple fibers, exhibits age-related loss of compactness in the arrangement of its nerve fibers.", + "summary_subclaims": [ + "We present the rare case of an asymptomatic, growing, left-sided ICA-PcomA aneurysm that was confirmed to split the oculomotor nerve.", + "The oculomotor nerve, which is an aggregate of multiple fibers, exhibits age-related loss of compactness in the arrangement of its nerve fibers." + ] + }, + { + "id": "multiclinsum_test_1288_en.txt", + "fulltext": "A 49-year-old man was referred to our hospital with a diagnosis of advanced right kidney cancer. He had visited the former doctor because of asymptomatic gross hematuria. Urine cytology was negative. Enhanced CT revealed a large right kidney tumor exceeding 20 cm in diameter, which was surrounded by abnormal neovascularization, and was pushing the liver and intestines to the left . On chest CT, multiple lung nodules were observed , which the diagnostic radiology team at our hospital diagnosed as multiple metastases. Therefore, a clinical diagnosis of cT3aN0M1 mRCC was made. A percutaneous needle biopsy provided us the pathological diagnosis of clear cell RCC . Among six International Metastatic RCC Database Consortium (IMDC) risk factors, time from diagnosis to treatment was applicable while other five factors were not; Karnofsky performance status was 90% and hemoglobin, neutrophils, platelets, and corrected calcium level were within the normal range. We considered systemic therapy as suitable for this patient, because immediate CN for this huge primary tumor and total metastasectomy for multiple lung tumors seemed too invasive. In addition, since IO-TKI combination was thought to be better suited for achieving remarkable tumor reduction than IO-IO, lenvatinib plus pembrolizumab combination therapy was administered as the first line of treatment. Starting dose of lenvatinib and pembrolizumab was 14 and 400 mg, respectively. During systemic therapy, the starting dose was maintained and no severe adverse event was observed, although the patient had grade 2 hypertension, grade 2 hand–foot syndrome, grade 1 diarrhea and grade 1 elevated transaminase levels. Nine weeks after administration of the combination therapy, the lung metastases disappeared, and the primary tumor and surrounding neovascularization shrank remarkably as revealed by the CT scan. An additional 10 weeks of treatment maintained the complete remission of the lung metastases and resulted in further shrinkage of the primary tumor to 13 cm in diameter , leading to a decision to perform DCN by a robot-assisted laparoscopic procedure. Twenty-three weeks after the treatment initiation (final administration of pembrolizumab in 19th week, and cessation of lenvatinib on pre-operative day 8), robot-assisted radical nephrectomy was successfully performed . The operative time was 219 min, and the console time was 146 min. The estimated blood loss was 330 mL without blood transfusion. No major surgical complication was observed. Histopathological analysis revealed ypT3a grade 2 clear cell RCC without sarcomatoid feature, and the surgical margin was negative. More than half of the specimen demonstrated coagulative necrosis, and viable cancer cells were observed in approximately 30% of the specimen. Dense lymphocyte infiltration was observed in juxtaposed necrosis and viable tumor tissue, suggesting an immune response activated by IO therapy . Immunohistochemistry confirmed CD4 and CD8 staining of these infiltrated lymphocytes . Surgical CR was achieved in this patient, and he is now in a treatment-free state.", + "fulltext_subclaims": [ + "The patient was a 49-year-old man.", + "He was referred to the hospital with a diagnosis of advanced right kidney cancer.", + "He had visited the former doctor because of asymptomatic gross hematuria.", + "Urine cytology was negative.", + "Enhanced CT revealed a large right kidney tumor exceeding 20 cm in diameter.", + "The tumor was surrounded by abnormal neovascularization.", + "The tumor was pushing the liver and intestines to the left.", + "On chest CT, multiple lung nodules were observed.", + "The diagnostic radiology team at the hospital diagnosed the lung nodules as multiple metastases.", + "A clinical diagnosis of cT3aN0M1 mRCC was made.", + "A percutaneous needle biopsy provided the pathological diagnosis of clear cell RCC.", + "Among six IMDC risk factors, time from diagnosis to treatment was applicable.", + "Karnofsky performance status was 90%.", + "Hemoglobin, neutrophils, platelets, and corrected calcium level were within the normal range.", + "Systemic therapy was considered suitable for this patient.", + "Immediate CN for the huge primary tumor and total metastasectomy for multiple lung tumors seemed too invasive.", + "IO-TKI combination was thought to be better suited for achieving remarkable tumor reduction than IO-IO.", + "Lenvatinib plus pembrolizumab combination therapy was administered as the first line of treatment.", + "The starting dose of lenvatinib was 14 mg.", + "The starting dose of pembrolizumab was 400 mg.", + "During systemic therapy, the starting dose was maintained.", + "No severe adverse event was observed.", + "The patient had grade 2 hypertension.", + "The patient had grade 2 hand–foot syndrome.", + "The patient had grade 1 diarrhea.", + "The patient had grade 1 elevated transaminase levels.", + "Nine weeks after administration of the combination therapy, the lung metastases disappeared.", + "The primary tumor and surrounding neovascularization shrank remarkably as revealed by the CT scan.", + "An additional 10 weeks of treatment maintained the complete remission of the lung metastases.", + "The primary tumor shrank to 13 cm in diameter.", + "A decision was made to perform DCN by a robot-assisted laparoscopic procedure.", + "Robot-assisted radical nephrectomy was successfully performed.", + "The operative time was 219 min.", + "The console time was 146 min.", + "The estimated blood loss was 330 mL without blood transfusion.", + "No major surgical complication was observed.", + "Histopathological analysis revealed ypT3a grade 2 clear cell RCC without sarcomatoid feature.", + "The surgical margin was negative.", + "More than half of the specimen demonstrated coagulative necrosis.", + "Viable cancer cells were observed in approximately 30% of the specimen.", + "Dense lymphocyte infiltration was observed in juxtaposed necrosis and viable tumor tissue.", + "This infiltration suggested an immune response activated by IO therapy.", + "Immunohistochemistry confirmed CD4 and CD8 staining of the infiltrated lymphocytes.", + "Surgical CR was achieved in this patient.", + "He is now in a treatment-free state." + ], + "summary": "A 49-year-old man was referred to our hospital with a diagnosis of advanced right kidney cancer with multiple lung metastases (cT3aN0M1). The size of the primary tumor was so huge that it exceeded 20 cm in diameter, pushing the liver and intestines to the left. After administration of lenvatinib and pembrolizumab combination as first-line treatment, all the metastatic lung lesions disappeared, and the primary lesion shrank significantly. Robot-assisted radical nephrectomy was successfully performed, resulting in complete surgical remission.", + "summary_subclaims": [ + "The patient was a 49-year-old man.", + "The diagnosis was advanced right kidney cancer with multiple lung metastases.", + "The size of the primary tumor exceeded 20 cm in diameter.", + "The tumor pushed the liver and intestines to the left.", + "Lenvatinib and pembrolizumab combination was administered as first-line treatment.", + "All the metastatic lung lesions disappeared after treatment.", + "The primary lesion shrank significantly after treatment.", + "Robot-assisted radical nephrectomy was successfully performed.", + "The result was complete surgical remission." + ] + }, + { + "id": "multiclinsum_test_1229_en.txt", + "fulltext": "A 50-year-old woman presented in the outpatient department with severe abdominal pain, especially in the left iliac region, for the past six months. The pain was dull aching in nature and continuous and used to be relieved with oral analgesics. The patient also complained of shortness of breath, which worsened in the supine position and was eased in the sitting posture. She also stated that she had lost her appetite and lost a large amount of weight. There was no history of vaginal bleeding. There was no previous medical or surgical history.\nOn physical examination, the patient looked cachexic with mild degree of pallor with stable vital parameters. Abdomen examination showed a mass of 20 weeks of gestation size with irregular surface, heterogeneous consistency, tender, margins well defined but the lower pole was usually not reached, with restricted mobility. Ascites was present and positive shifting dullness was noted. A vaginal examination showed nodules on the right posterior fornix, tenderness was present. Left fornix was free.\nThe patient was advised for contrast-enhanced computed tomography (CECT) of the abdomen and pelvis, which revealed a large cystic lesion with peripheral enhancing solid areas in the pelvis in midline, probably arising from the left ovary, a possibility of malignant ovarian lesion . Another heterogeneously enhancing lesion was seen in the right adnexa. The right ovary was not seen separately from the lesion. There was a large ill-defined heterogeneously enhancing central mesenteric lesion with omental extension showing dense calcification, most likely metastatic deposit. Loculated ascites and left-sided moderate pleural effusion with few peripheral lung parenchymal nodules in the right middle and bilateral lower lobes were suggestive of stage 4A of the International Federation of Gynecology and Obstetrics system 2014.\nCA-125 (cancer antigen 125) value was more than 1000 units/ml. NACT was given to the patient with paclitaxel 175 mg/m2 and carboplatin 675 mg/m2 (area under the curve (AUC)=5-6, calculated by Calvert’s formula). After two cycles of NACT with intervals of three weeks, CA-125 was 452 units/ml. The patient then underwent further four cycles of NACT. CA-125 was repeated, which showed normal values, and CECT was done, which revealed a complex cystic lesion in the pelvis and the infra-umbilical region at midline and para midline locations . A lesion of 2-3 cm thickness and peripherally enhancing solid mass of 8.6 x 5.8 cm in size was displacing the adjacent bowel loop. There was para midline location-significant regression in size of the mass. There was significant regression in ascites.\nUSG revealed a solid cystic lesion in the left adnexa measuring 5 x 4.2 x 3.6 cm; the solid component showed vascularity. Left ovary not seen separately. Findings were consistent with left ovarian complex cyst-neoplastic etiology. Omental thickening was seen in midline in the epigastric region.\nThe patient was taken for exploratory laparotomy. A vertical incision of 10 cm was made and the abdomen was opened in layers so as to expose the maximum area. In order to assess the extent of the primary tumor and metastatic disease, the peritoneal cavity and retroperitoneum were thoroughly inspected and palpated. All abdominal viscera were palpated and checked, and adhesions between sigmoid and left corn structures were lysed. Ureters were identified and placed away. Dissection of mass, uterus, cervix, bilateral fallopian tube, and ovaries was done by retroperitoneal approach and sent for frozen section according to which it was labeled as bilateral papillary cystadenocarcinoma. Then retroperitoneal resection was done. Bilateral pelvic lymph nodes were removed and an omentectomy was done. No para-aortic lymph nodes were identified. The bowel was inspected for injury. Drain was inserted and hemostasis was achieved. Rectus was closed with prolene 1-0. All laparotomy sponges and instruments were removed from the abdomen and counted. The abdomen was closed in layers with Vicryl 1. Skin closure was done in layers with Ethilon 2-0 mattress sutures. The patient withstood the procedure satisfactorily and was shifted to the postoperative ward. Specimens were sent for histopathology, which confirmed bilateral serous cystadenocarcinoma. The specimen is shown in Figure .\nThe patient was discharged on postoperative day 12 after suture removal and advised to follow up every month for the first three months and then every three months for the next one year. On her last follow-up, the patient was better clinically and had no signs of recurrence.", + "fulltext_subclaims": [ + "A 50-year-old woman presented with severe abdominal pain in the left iliac region for the past six months.", + "The pain was dull aching in nature and continuous.", + "The pain was relieved with oral analgesics.", + "The patient also complained of shortness of breath.", + "Shortness of breath worsened in the supine position.", + "Shortness of breath was eased in the sitting posture.", + "The patient had lost her appetite.", + "The patient had lost a large amount of weight.", + "There was no history of vaginal bleeding.", + "There was no previous medical or surgical history.", + "On physical examination, the patient looked cachexic.", + "Abdomen examination showed a mass of 20 weeks of gestation size.", + "The mass had an irregular surface.", + "The mass had heterogeneous consistency.", + "The mass was tender.", + "The mass had well-defined margins.", + "The lower pole of the mass was usually not reached.", + "The mass had restricted mobility.", + "Ascites was present.", + "Positive shifting dullness was noted.", + "A vaginal examination showed nodules on the right posterior fornix.", + "Tenderness was present on the right posterior fornix.", + "The left fornix was free.", + "The patient was advised for contrast-enhanced computed tomography (CECT) of the abdomen and pelvis.", + "CECT revealed a large cystic lesion with peripheral enhancing solid areas in the pelvis.", + "The lesion was probably arising from the left ovary.", + "A possibility of malignant ovarian lesion was noted.", + "Another heterogeneously enhancing lesion was seen in the right adnexa.", + "The right ovary was not seen separately from the lesion.", + "A large ill-defined heterogeneously enhancing central mesenteric lesion with omental extension showing dense calcification was noted.", + "The mesenteric lesion was most likely metastatic deposit.", + "Loculated ascites was noted.", + "Left-sided moderate pleural effusion was noted.", + "Few peripheral lung parenchymal nodules were seen in the right middle and bilateral lower lobes.", + "The findings were suggestive of stage 4A of the International Federation of Gynecology and Obstetrics system 2014.", + "CA-125 value was more than 1000 units/ml.", + "NACT was given to the patient with paclitaxel 175 mg/m2 and carboplatin 675 mg/m2.", + "The AUC for carboplatin was 5-6, calculated by Calvert’s formula.", + "After two cycles of NACT, CA-125 was 452 units/ml.", + "The patient then underwent four cycles of NACT.", + "After NACT, CA-125 showed normal values.", + "CECT after NACT revealed a complex cystic lesion in the pelvis and the infra-umbilical region.", + "The lesion was at midline and para midline locations.", + "A lesion of 2-3 cm thickness and peripherally enhancing solid mass of 8.6 x 5.8 cm in size was displacing the adjacent bowel loop.", + "There was para midline location.", + "There was significant regression in size of the mass.", + "There was significant regression in ascites.", + "USG revealed a solid cystic lesion in the left adnexa measuring 5 x 4.2 x 3.6 cm.", + "The solid component showed vascularity.", + "The left ovary was not seen separately.", + "Findings were consistent with left ovarian complex cyst-neoplastic etiology.", + "Omental thickening was seen in midline in the epigastric region.", + "The patient was taken for exploratory laparotomy.", + "A vertical incision of 10 cm was made.", + "The abdomen was opened in layers.", + "The peritoneal cavity and retroperitoneum were thoroughly inspected and palpated.", + "All abdominal viscera were palpated and checked.", + "Adhesions between sigmoid and left corn structures were lysed.", + "Ureters were identified and placed away.", + "Dissection of mass, uterus, cervix, bilateral fallopian tube, and ovaries was done by retroperitoneal approach.", + "Frozen section labeled it as bilateral papillary cystadenocarcinoma.", + "Retroperitoneal resection was done.", + "Bilateral pelvic lymph nodes were removed.", + "An omentectomy was done.", + "No para-aortic lymph nodes were identified.", + "The bowel was inspected for injury.", + "A drain was inserted.", + "Hemostasis was achieved.", + "Rectus was closed with prolene 1-0.", + "All laparotomy sponges and instruments were removed from the abdomen and counted.", + "The abdomen was closed in layers with Vicryl 1.", + "Skin closure was done in layers with Ethilon 2-0 mattress sutures.", + "The patient was shifted to the postoperative ward.", + "Specimens were sent for histopathology.", + "Histopathology confirmed bilateral serous cystadenocarcinoma.", + "The patient was discharged on postoperative day 12 after suture removal.", + "The patient was advised to follow up every month for the first three months.", + "The patient was advised to follow up every three months for the next one year.", + "On her last follow-up, the patient was better clinically.", + "On her last follow-up, the patient had no signs of recurrence." + ], + "summary": "A 50-year-old female with P2L2A2 (Para-2, Live-2, Abortion-2) presented with pain in the abdomen for six months. Investigations were done, which revealed bilateral large ovarian cystic lesion suggestive of ovarian malignancy. She underwent six cycles of chemotherapy followed by exploratory laparotomy.", + "summary_subclaims": [ + "The patient is a 50-year-old female.", + "The patient has P2L2A2.", + "The patient presented with pain in the abdomen for six months.", + "Investigations revealed bilateral large ovarian cystic lesion.", + "The ovarian cystic lesion was suggestive of ovarian malignancy.", + "The patient underwent six cycles of chemotherapy.", + "The patient underwent exploratory laparotomy." + ] + }, + { + "id": "multiclinsum_test_792_en.txt", + "fulltext": "A 37-year-old Indonesian woman was brought to the emergency department (ED) at 36 weeks gestation in her second pregnancy with shortness of breath that worsened 1 day before admission. She had a fever and bloody phlegm cough within the last 2 days, accompanied by painful swallowing and hoarseness for 2 months. She also had worsening gastroesophageal reflux disease (GERD) without medication, as well as a history of thyroidectomy due to malignancy 2 years ago.\nUpon arrival, she had a respiratory rate of 26–30 breaths per minute, SpO2 of 98% on nasal oxygen supplementation, pulse rate of 110–120 beats per minute, and blood pressure of 172/92 mmHg. The pregnancy ultrasound showed a single live intrauterine fetus with a normal fetal heart rate [estimated fetal weight (EFW) 2184 g], corresponding to 36 weeks of gestation, and no cervical dilation. Laboratory tests revealed leukocytosis of 17,000/µL and proteinuria. Other tests such as albumin, electrolytes, and coagulation profile were within normal range. A preliminary diagnosis of pneumonia or heart failure was made in the ED. The patient was initially treated with ceftizoxime 1 g injection t.i.d. and furosemide 20 mg injection, and was planned to be admitted to the intensive care unit (ICU). However, later the chest X-ray showed neither signs of infiltrates nor pulmonary edema, and echocardiography showed normal left and right heart function.\nWe suspected laryngeal edema in the ICU due to the patient’s preeclamptic condition and stridor, which was initially treated with an empirical methylprednisolone injection of 125 mg t.i.d. and nebulized epinephrine. Pantoprazole 40 mg injection b.i.d. was also administered to overcome GERD.\nA total of 16 hours after admission to the ICU, her condition deteriorated, with worsened tachypnea, decreased oxygen saturation, and an inability to talk, so we decided to perform intubation. Mask ventilation was used for preoxygenation, and no difficulty was encountered. Intubation was facilitated by administering propofol (1.5 mg/kg BW) and fentanyl (1 μg/kg BW). We could only use 6.0-sized endotracheal tube (ETT) because of the edematous larynx. We stopped giving sedation after the patient could tolerate the use of ETT. Pressure support ventilator mode and spontaneous breathing with T-tube were used, taking turns.\nThe following days, a fiberoptic bronchoscopy revealed uneven granular vocal cords with multiple white plaques and a swollen red appearance due to laryngeal edema . Due to a suspicion of fungal infection based on bronchoscopy findings, methylprednisolone was stopped and additional treatment of fluconazole 800 mg, then 400 mg q.d., was given.\nThe use of a small-sized ETT was expected to be short-lived, so she was considered for tracheostomy. Nevertheless, we decided to perform a cesarean section first after lung maturation because it would be safer for the fetus, and laryngeal edema usually improves after delivery.\nDespite the fact that the patient was still using ETT, she was utterly cooperative, so spinal anesthesia was given instead of general anesthesia . Hyperbaric bupivacaine 10 mg with fentanyl 25 μg was administered from the L4/L5 interspace. There were no intraoperative problems. She was readmitted to the ICU after surgery with no significant complaints, and 48 hours after delivery, her clinical and vital signs were stable.\nExtubation was performed after a positive result from the leakage test. Stridor was no longer audible, breathing pattern was within normal limits, and vital signs were stable, although the patient still could not talk. She was transferred to the ward for postpartum care. A laryngeal lavage fluid sample was taken during the bronchoscopy for culture, and a week later, the result came back with Enterobacter aerogenes.\nAfter 2 days of treatment in the ward, the patient was discharged from the hospital. She returned to our hospital 2 weeks later for a post-discharge follow-up, and her condition improved. The baby was also in good health. Table presents a timeline of the case history.", + "fulltext_subclaims": [ + "The patient was a 37-year-old Indonesian woman.", + "She was brought to the emergency department at 36 weeks gestation.", + "She had shortness of breath that worsened 1 day before admission.", + "She had a fever and bloody phlegm cough within the last 2 days.", + "She had painful swallowing and hoarseness for 2 months.", + "She had worsening gastroesophageal reflux disease without medication.", + "She had a history of thyroidectomy due to malignancy 2 years ago.", + "Upon arrival, she had a respiratory rate of 26–30 breaths per minute.", + "Her SpO2 was 98% on nasal oxygen supplementation.", + "Her pulse rate was 110–120 beats per minute.", + "Her blood pressure was 172/92 mmHg.", + "The pregnancy ultrasound showed a single live intrauterine fetus.", + "The estimated fetal weight was 2184 g.", + "The estimated fetal weight corresponded to 36 weeks of gestation.", + "There was no cervical dilation.", + "Laboratory tests revealed leukocytosis of 17,000/µL.", + "Laboratory tests revealed proteinuria.", + "Other tests such as albumin, electrolytes, and coagulation profile were within normal range.", + "A preliminary diagnosis of pneumonia or heart failure was made.", + "The patient was initially treated with ceftizoxime 1 g injection t.i.d.", + "The patient was initially treated with furosemide 20 mg injection.", + "The patient was planned to be admitted to the intensive care unit.", + "The chest X-ray showed neither signs of infiltrates nor pulmonary edema.", + "Echocardiography showed normal left and right heart function.", + "We suspected laryngeal edema due to the patient’s preeclamptic condition and stridor.", + "We initially treated laryngeal edema with an empirical methylprednisolone injection of 125 mg t.i.d.", + "We initially treated laryngeal edema with nebulized epinephrine.", + "Pantoprazole 40 mg injection b.i.d. was administered to overcome GERD.", + "A total of 16 hours after admission to the ICU, her condition deteriorated.", + "She had worsened tachypnea.", + "She had decreased oxygen saturation.", + "She had an inability to talk.", + "We decided to perform intubation.", + "Mask ventilation was used for preoxygenation.", + "No difficulty was encountered during intubation.", + "Intubation was facilitated by administering propofol (1.5 mg/kg BW).", + "Intubation was facilitated by administering fentanyl (1 μg/kg BW).", + "A 6.0-sized endotracheal tube was used because of the edematous larynx.", + "Sedation was stopped after the patient could tolerate the use of ETT.", + "Pressure support ventilator mode and spontaneous breathing with T-tube were used, taking turns.", + "A fiberoptic bronchoscopy revealed uneven granular vocal cords.", + "A fiberoptic bronchoscopy revealed multiple white plaques.", + "A fiberoptic bronchoscopy revealed a swollen red appearance due to laryngeal edema.", + "A suspicion of fungal infection was based on bronchoscopy findings.", + "Methylprednisolone was stopped.", + "Fluconazole 800 mg was given.", + "Fluconazole 400 mg q.d. was given.", + "A cesarean section was decided after lung maturation.", + "Spinal anesthesia was given instead of general anesthesia.", + "Hyperbaric bupivacaine 10 mg with fentanyl 25 μg was administered from the L4/L5 interspace.", + "There were no intraoperative problems.", + "She was readmitted to the ICU after surgery with no significant complaints.", + "48 hours after delivery, her clinical and vital signs were stable.", + "Extubation was performed after a positive result from the leakage test.", + "Stridor was no longer audible.", + "Breathing pattern was within normal limits.", + "Vital signs were stable after extubation.", + "She was transferred to the ward for postpartum care.", + "A laryngeal lavage fluid sample was taken during the bronchoscopy for culture.", + "The culture result came back with Enterobacter aerogenes.", + "After 2 days of treatment in the ward, the patient was discharged from the hospital.", + "She returned to the hospital 2 weeks later for a post-discharge follow-up.", + "Her condition improved.", + "The baby was also in good health." + ], + "summary": "A 37-year-old Indonesian woman was brought to the emergency department at 36 weeks gestation due to severe dyspnea. Her condition worsened a few hours later during intensive care unit admission, with tachypnea, decreased oxygen saturation, and inability to communicate, necessitating intubation. Due to the edematous larynx, we could only use 6.0-sized endotracheal tube. The use of a small-sized endotracheal tube was expected to be short-lived, so she was considered for tracheostomy. Nevertheless, we decided to perform a cesarean section first after lung maturation because it would be safer for the fetus, and laryngeal edema usually improves after delivery. Cesarean section was performed under spinal anesthesia for the safety of the fetus, and 48 hours after delivery, she underwent a leakage test with a positive result, so extubation was performed. Stridor was no longer audible, breathing pattern was within normal limits, and vital signs were stable. The patient and her baby both recovered well with no long-term health consequences.", + "summary_subclaims": [ + "A 37-year-old Indonesian woman was brought to the emergency department at 36 weeks gestation due to severe dyspnea.", + "Her condition worsened a few hours later during intensive care unit admission.", + "She had tachypnea.", + "She had decreased oxygen saturation.", + "She was unable to communicate.", + "Intubation was necessitated.", + "Due to the edematous larynx, a 6.0-sized endotracheal tube was used.", + "The use of a small-sized endotracheal tube was expected to be short-lived.", + "She was considered for tracheostomy.", + "A cesarean section was performed first after lung maturation.", + "The cesarean section was performed under spinal anesthesia.", + "Forty-eight hours after delivery, she underwent a leakage test with a positive result.", + "Extubation was performed.", + "Stridor was no longer audible.", + "Breathing pattern was within normal limits.", + "Vital signs were stable.", + "The patient and her baby both recovered well.", + "There were no long-term health consequences." + ] + }, + { + "id": "multiclinsum_test_1778_en.txt", + "fulltext": "A 53-year-old Japanese woman with no significant medical history other than chronic gastritis, diagnosed by upper gastrointestinal endoscopy 6 years previously, presented to our hospital with a mass in the larynx that appeared to be malignant. She had a 1-year history of a dull feeling in her throat and cough. Three months earlier, she had been diagnosed with anisakiasis at a local clinic and had been incidentally found to have mass lesion of approximately 7-mm in diameter at the left tongue base, by upper gastrointestinal endoscopy. One month earlier, follow-up nasopharyngoscopy had revealed no changes in the mass lesion, and an endoscopic biopsy had been performed. Squamous cell carcinoma was suspected pathologically, and the patient was referred to the department of otorhinolaryngology at our hospital for further evaluation.\nAn endoscopic biopsy was also performed in our outpatient clinic , but the biopsy specimens only showed atypical epithelium, and the scrape culture was negative. Intravenous contrast-enhanced computed tomography (CT) of the neck and thorax was unremarkable, except for bilateral cervical lymphadenopathy.\nFor further evaluation, an excision biopsy under general anesthesia was performed . Histopathological examination of a hematoxylin and eosin-stained biopsy specimen showed granulomatous tissue consisting mainly of histiocytes and multinucleated giant cells . Some histiocytes had phagocytized the encapsulated yeast-like organisms that were invading the epithelium. There were also scant neutrophils, but no micro-abscesses were found. The walls of the mass were positive on staining with Grocott’s methenamine silver . These findings suggested cryptococcosis; therefore, she was referred to the Department of Infectious Disease for the treatment of the residual mass lesion.\nOn physical examination, the patient was afebrile, and her vital signs were normal. Head and neck examination revealed no enlarged lymph nodes, and no meningeal signs. Examination of the pharynx revealed no pharyngeal edema or exudate. She had no skin lesions. The blood test results were unremarkable. An HIV antibody/antigen combination test result was negative. A neutrophil function test was not performed because she did not have a history of recurrent or severe bacterial infection, suggesting that her neutrophil function was normal. Chest CT revealed no pulmonary findings of note. A serum Cryptococcus antigen test (Bio-Medical Laboratories, Inc.), using a latex agglutination method was negative. Serum beta D glucan was not measured. Based on these findings and the histopathology, she was provisionally diagnosed with possible non-meningeal, non-pulmonary cryptococcosis. The scrape culture of the residual lesion at the base of the tongue was repeated, and then fosfluconazole treatment (6 mg/kg bodyweight/day) was initiated as treatment for localized cryptococcosis.\nAfter 3 days of incubation of the separation culture that targeted Cryptococcus from the scrape specimen, white to pale purple-colored small colonies grew on the XM-Candida agar plate (Nissui Pharmaceutical Co., Ltd., Tokyo, Japan) cultured at 35 °C in aerobic conditions . The VITEK® 2 COMPACT Microbial Detection System (version 8.01 database: SYSMEX bioMérieux Co., Ltd., Tokyo, Japan) based on the biochemical reaction method with yeast identification card identified the colonies as P. wickerhamii. Matrix-assisted laser desorption/ionization time-of-flight mass spectrometry (MALDI-TOF MS, using the MALDI Biotyper version 4.0.0.1 database; Bruker Daltonik, Germany) did not identify the colonies initially, but in the re-examination, it identified the colonies as P. wickerhamii with low probability (score 1.451). Lactophenol cotton blue staining of the colony revealed tightly packed endospores within the sporangia distinctive of P. wickerhamii .\nDNA was extracted and polymerase chain reaction (PCR) method was performed using primers to amplify the internal transcribed spacer region and the D1/D2 domain of the large subunit ribosomal DNA gene. Sequence analysis of the amplicons showed no significant results, suggesting genetic polymorphism. Cloning was performed, and base sequences showing high homology with P. wickerhamii genes were detected.\nTherefore, a diagnosis of laryngeal protothecosis was established. The minimum inhibitory concentration (MIC) results using the Frozen Plate for Antifungal Susceptibility Testing of Yeasts, Eiken (Eiken Chemical Co., Ltd., Tokyo) were as follows: amphotericin B, 1 µg/mL; fluconazole, > 64 µg/mL; itraconazole, 4 µg/mL; voriconazole, 1 µg/mL; miconazole, > 16 µg/mL; flucytosine, > 64 µg/mL; and micafungin, > 16 µg/mL. Empiric fosfluconazole treatment was discontinued after 10 weeks because the size of the residual mass lesion did not change. Amphotericin B syrup (1 mL, 4 times a day) was initiated and continued for 6 weeks instead of intravenous amphotericin B treatment because the patient was asymptomatic and could not take time off from work to be admitted to hospital for intravenous amphotericin B treatment. Although we considered additional and definitive resection after the patient was diagnosed with Prototheca infection, we decided against it because we anticipated that it would be difficult to remove the lesion with safety margins because the vertical margin was not clearly determined on macroscopic examination, and resection carried a risk of causing difficulties with speech and swallowing. The residual mass lesion did not deteriorate during the antifungal treatment or the post-treatment one-year follow-up period.", + "fulltext_subclaims": [ + "The patient was a 53-year-old Japanese woman.", + "She had no significant medical history other than chronic gastritis.", + "Chronic gastritis was diagnosed by upper gastrointestinal endoscopy 6 years previously.", + "She presented with a mass in the larynx that appeared to be malignant.", + "She had a 1-year history of a dull feeling in her throat and cough.", + "Three months earlier, she had been diagnosed with anisakiasis at a local clinic.", + "Three months earlier, she was incidentally found to have a mass lesion of approximately 7-mm in diameter at the left tongue base by upper gastrointestinal endoscopy.", + "One month earlier, follow-up nasopharyngoscopy had revealed no changes in the mass lesion.", + "One month earlier, an endoscopic biopsy had been performed.", + "Squamous cell carcinoma was suspected pathologically.", + "The patient was referred to the department of otorhinolaryngology at our hospital for further evaluation.", + "An endoscopic biopsy was also performed in our outpatient clinic.", + "The biopsy specimens only showed atypical epithelium.", + "The scrape culture was negative.", + "Intravenous contrast-enhanced computed tomography (CT) of the neck and thorax was unremarkable, except for bilateral cervical lymphadenopathy.", + "An excision biopsy under general anesthesia was performed.", + "Histopathological examination showed granulomatous tissue consisting mainly of histiocytes and multinucleated giant cells.", + "Some histiocytes had phagocytized the encapsulated yeast-like organisms that were invading the epithelium.", + "There were also scant neutrophils, but no micro-abscesses were found.", + "The walls of the mass were positive on staining with Grocott’s methenamine silver.", + "These findings suggested cryptococcosis.", + "She was referred to the Department of Infectious Disease for the treatment of the residual mass lesion.", + "On physical examination, the patient was afebrile.", + "Her vital signs were normal.", + "Head and neck examination revealed no enlarged lymph nodes.", + "No meningeal signs were found.", + "Examination of the pharynx revealed no pharyngeal edema or exudate.", + "She had no skin lesions.", + "The blood test results were unremarkable.", + "An HIV antibody/antigen combination test result was negative.", + "A neutrophil function test was not performed.", + "Chest CT revealed no pulmonary findings of note.", + "A serum Cryptococcus antigen test was negative.", + "Serum beta D glucan was not measured.", + "Based on these findings and the histopathology, she was provisionally diagnosed with possible non-meningeal, non-pulmonary cryptococcosis.", + "The scrape culture of the residual lesion at the base of the tongue was repeated.", + "Fosfluconazole treatment (6 mg/kg bodyweight/day) was initiated as treatment for localized cryptococcosis.", + "After 3 days of incubation, white to pale purple-colored small colonies grew on the XM-Candida agar plate.", + "The VITEK® 2 COMPACT Microbial Detection System identified the colonies as P. wickerhamii.", + "Matrix-assisted laser desorption/ionization time-of-flight mass spectrometry did not identify the colonies initially.", + "In re-examination, it identified the colonies as P. wickerhamii with low probability (score 1.451).", + "Lactophenol cotton blue staining of the colony revealed tightly packed endospores within the sporangia distinctive of P. wickerhamii.", + "DNA was extracted and polymerase chain reaction was performed.", + "Sequence analysis of the amplicons showed no significant results, suggesting genetic polymorphism.", + "Cloning was performed, and base sequences showing high homology with P. wickerhamii genes were detected.", + "A diagnosis of laryngeal protothecosis was established.", + "The minimum inhibitory concentration results showed amphotericin B at 1 µg/mL.", + "The minimum inhibitory concentration results showed fluconazole at > 64 µg/mL.", + "The minimum inhibitory concentration results showed itraconazole at 4 µg/mL.", + "The minimum inhibitory concentration results showed voriconazole at 1 µg/mL.", + "The minimum inhibitory concentration results showed miconazole at > 16 µg/mL.", + "The minimum inhibitory concentration results showed flucytosine at > 64 µg/mL.", + "The minimum inhibitory concentration results showed micafungin at > 16 µg/mL.", + "Empiric fosfluconazole treatment was discontinued after 10 weeks.", + "Amphotericin B syrup (1 mL, 4 times a day) was initiated and continued for 6 weeks.", + "We decided against additional and definitive resection because we anticipated that it would be difficult to remove the lesion with safety margins.", + "The residual mass lesion did not deteriorate during the antifungal treatment or the post-treatment one-year follow-up period." + ], + "summary": "We report a case of Prototheca wickerhamii infection in the mucosa of the pharynx in a 53-year-old immunocompetent woman with an incidentally found mass lesion at the left tongue base. Histopathological findings of the mass lesion suggested cryptococcosis, but P. wickerhamii was identified from the oropharynx scrape culture based on DNA sequencing. After surgical resection, fosfluconazole treatment was initiated, and subsequently, treatment was switched to topical amphotericin B. The residual mass lesion did not deteriorate during the 4-month antifungal treatment and 1-year observational period.", + "summary_subclaims": [ + "The patient was a 53-year-old immunocompetent woman.", + "A mass lesion was incidentally found at the left tongue base.", + "Histopathological findings of the mass lesion suggested cryptococcosis.", + "Prototheca wickerhamii was identified from the oropharynx scrape culture based on DNA sequencing.", + "Fosfluconazole treatment was initiated after surgical resection.", + "Treatment was switched to topical amphotericin B.", + "The residual mass lesion did not deteriorate during the 4-month antifungal treatment.", + "The residual mass lesion did not deteriorate during the 1-year observational period." + ] + }, + { + "id": "multiclinsum_test_1779_en.txt", + "fulltext": "A 53-year-old Chinese lady, with a history of hypertension, diabetes mellitus and chronic depression, presented with an 8 month duration of severe medial right knee pain associated with varus knee deformity. Pain was exacerbated on walking and standing. She was initially treated conservatively with a course of non-steroidal inflammatory drugs, intra-articular visco-supplementation, physiotherapy and weight loss regime. Despite a two-year trial of non-surgical therapy, she continued to experience a deterioration in her symptoms with limitation ofher functional status requiring a quadstick as a walking aid. Clinical examination revealed bilateral genu varum. Range of motion was limited to 0 to 110° with no fixed flexion deformity found bilaterally. Significantly, there was medial joint line tenderness and absence of lateral joint line and patellofemoral tenderness. Minimal effusion was found in the right knee. No limb length discrepancy or varus knee thrust was found. Bilateral weight-bearing knee and long limb radiographs were performed . Significant medial compartment radiographic osteoarthritic changes were noted in the right knee, corresponding to Kellgren-Lawrence grade 3 osteoarthritis. These changes included loss of medial joint space, varus knee deformity and the presence of marginal osteophytes. The femoral-tibial angle measured was 175° and the anatomical lateral distal femoral angle was 86°. We performed a diagnostic knee arthroscopy and then proceeded to an opening wedge high tibial osteotomy using the Tomofix plate after a failed two year trial of conservative therapy . Arthroscopic findings include medial compartment Outer bridge grade 4 lesion with degenerate radial tear of the posterior horn of the medial meniscus. The lateral compartment had no cartilage or meniscal tear. Intra-operative correction with the opening wedge osteotomy was guided with the use of radiographic imaging. Post-operatively, she was started on a rehabilitation programme, progressing to partial weight bearing at about 6 weeks.\nHowever, she continued to experience pain over the osteotomy site up till 6 months post operatively. Pain was exacerbated on standing and ambulation. Repeat radiographs showed minimal callus formation over previous osteotomy site . She was treated conservatively with continued protected weight bearing. However, her symptoms deteriorated and she developed a fix flexion deformity of her right knee. A computed tomogram performed 8 month postoperatively revealed non-union of the osteotomy site with hardware failure and loss of correction . Three proximal screws were broken and 1 screw had back-out. The proximal tibia was angulated laterally in varus and anteriorly increasing the tibial plateau slope. Inflammatory markers were not elevated.\nThe patient subsequently underwent revision plating with autologous bone graft. The surgical approach was similar to the index surgery. Intra-operatively, findings were consistent with CT scan results. The screws were completely removed together with the Tomofix plate. Bone edges were freshened and the alignment was corrected under radiographic imaging guidance. Autologous cancellous iliac crest bone grafts were harvested and compacted into the osteotomy site. A proximal tibial locking plate was placed on the posteromedial aspect and locking screws were used to secure the fixation. The previous plate was medial. Intraoperative cultures sent were negative for infection. Post-operatively, the patient progressed from non-weight bearing to partial weight bearing at 3 months and full weight-bearing at 6 months post-operatively. She no longer experienced pain at the osteotomy site and repeat radiographs performed at 1 year post-operatively showed union . She was able to ambulate without any walking aids and no longer has any limitations in her daily activities.", + "fulltext_subclaims": [ + "The patient is a 53-year-old Chinese lady.", + "She has a history of hypertension.", + "She has a history of diabetes mellitus.", + "She has a history of chronic depression.", + "She presented with an 8 month duration of severe medial right knee pain.", + "The pain was associated with varus knee deformity.", + "Pain was exacerbated on walking and standing.", + "She was initially treated with a course of non-steroidal inflammatory drugs.", + "She received intra-articular visco-supplementation.", + "She underwent physiotherapy.", + "She was placed on a weight loss regime.", + "Despite a two-year trial of non-surgical therapy, she continued to experience deterioration in her symptoms.", + "She required a quadstick as a walking aid.", + "Clinical examination revealed bilateral genu varum.", + "Range of motion was limited to 0 to 110° bilaterally.", + "There was no fixed flexion deformity found bilaterally.", + "There was medial joint line tenderness.", + "There was absence of lateral joint line tenderness.", + "There was absence of patellofemoral tenderness.", + "Minimal effusion was found in the right knee.", + "No limb length discrepancy was found.", + "No varus knee thrust was found.", + "Bilateral weight-bearing knee and long limb radiographs were performed.", + "Significant medial compartment radiographic osteoarthritic changes were noted in the right knee.", + "The changes corresponded to Kellgren-Lawrence grade 3 osteoarthritis.", + "The changes included loss of medial joint space.", + "The changes included varus knee deformity.", + "The changes included the presence of marginal osteophytes.", + "The femoral-tibial angle measured was 175°.", + "The anatomical lateral distal femoral angle was 86°.", + "A diagnostic knee arthroscopy was performed.", + "An opening wedge high tibial osteotomy using the Tomofix plate was performed.", + "The osteotomy was performed after a failed two year trial of conservative therapy.", + "Arthroscopic findings included a medial compartment Outerbridge grade 4 lesion.", + "Arthroscopic findings included a degenerate radial tear of the posterior horn of the medial meniscus.", + "The lateral compartment had no cartilage or meniscal tear.", + "Intra-operative correction with the opening wedge osteotomy was guided with the use of radiographic imaging.", + "Post-operatively, she was started on a rehabilitation programme.", + "She progressed to partial weight bearing at about 6 weeks.", + "She continued to experience pain over the osteotomy site up till 6 months post operatively.", + "Pain was exacerbated on standing and ambulation.", + "Repeat radiographs showed minimal callus formation over the previous osteotomy site.", + "She was treated with continued protected weight bearing.", + "Her symptoms deteriorated.", + "She developed a fixed flexion deformity of her right knee.", + "A computed tomogram performed 8 months postoperatively revealed non-union of the osteotomy site.", + "The computed tomogram showed hardware failure and loss of correction.", + "Three proximal screws were broken.", + "One screw had back-out.", + "The proximal tibia was angulated laterally in varus.", + "The proximal tibia was angulated anteriorly increasing the tibial plateau slope.", + "Inflammatory markers were not elevated.", + "The patient underwent revision plating with autologous bone graft.", + "The surgical approach was similar to the index surgery.", + "Intra-operatively, findings were consistent with CT scan results.", + "The screws were completely removed together with the Tomofix plate.", + "Bone edges were freshened.", + "The alignment was corrected under radiographic imaging guidance.", + "Autologous cancellous iliac crest bone grafts were harvested.", + "The grafts were compacted into the osteotomy site.", + "A proximal tibial locking plate was placed on the posteromedial aspect.", + "Locking screws were used to secure the fixation.", + "The previous plate was medial.", + "Intraoperative cultures sent were negative for infection.", + "Post-operatively, the patient progressed from non-weight bearing to partial weight bearing at 3 months.", + "She progressed to full weight-bearing at 6 months post-operatively.", + "She no longer experienced pain at the osteotomy site.", + "Repeat radiographs performed at 1 year post-operatively showed union.", + "She was able to ambulate without any walking aids.", + "She no longer has any limitations in her daily activities." + ], + "summary": "We present a case of persistent non-union after high tibial osteotomy treated with autologous iliac crest bone grafting and revision plating. At 1 year post-operative interval, successful union was achieved after revision internal fixation. In addition, a good functional outcome was achieved.", + "summary_subclaims": [ + "We present a case of persistent non-union after high tibial osteotomy.", + "The patient was treated with autologous iliac crest bone grafting.", + "The patient was treated with revision plating.", + "At 1 year post-operative interval, successful union was achieved after revision internal fixation.", + "A good functional outcome was achieved." + ] + }, + { + "id": "multiclinsum_test_2877_en.txt", + "fulltext": "An 83-year-old man with a history of third-degree AV block and a single-chamber (RV lead) permanent pacing system (in situ 9 years) was referred to our institution with worsening breathlessness (NYHA III). There were no other heart failure symptoms, and clinical examination revealed signs of fluid overload (elevated jugular venous pressure and bilateral lower leg oedema) with no murmurs on auscultation.\nThis included an ablation for cavo-tricuspid isthmus dependent flutter in 2009, and mild chronic obstructive pulmonary disease. There was a remote history of alcohol excess and transthoracic echocardiography at the time of original device implantation showed preserved left ventricular systolic function (LVEF 55%).\nDrug therapy included Ramipril 10 mg o.d., Spironolactone 25 mg o.d., Bendroflumethiazide 2.5 mg o.d., Simvastatin 40 mg o.d., Omeprazole 20 mg o.d., Tiotropium 18 µg o.d., Symbicort Turbohaler 200 µg/6 µg 1 puff BD, and Warfarin according to internal normalized ratio. Betablockers had not been commenced due to concerns about airways disease with a degree of reversibility on pulmonary functional testing.\nTwelve-lead electrocardiogram (ECG) showed sinus rhythm with AV dissociation because of RV-only pacing . Device interrogation confirmed 100% RV pacing with underlying complete AV block with a broad escape rhythm (left bundle branch block [LBBB], QRS duration 132 ms). Transthoracic echocardiography revealed a non-dilated LV with moderately impaired systolic function (LVEF 40–45%) with evidence of dyssynchrony (apical rocking and early septal activation) consistent with RV apical pacing (see , ). RV function and pulmonary pressures were normal, with no significant valve abnormalities.\nThe most likely diagnosis explaining this presentation was PIC, differentials included alcohol-induced cardiomyopathy, or post-ablation atrial arrhythmia.\nDespite guideline-directed medical therapy his heart failure symptoms persisted. Considering the LV impairment and dyssynchronous ventricular activation, he was offered a device upgrade to a CRT-P with either a conventional LV lead or a His-bundle lead, in addition to a right atrial (RA) lead to improve VV and AV synchrony, respectively. Prior to implantation, left-sided venography was performed to evaluate vein patency which showed an occluded SCV . Options considered included the following: (i) a contralateral CRT-P implantation; (ii) implanting a right-sided RA and LV lead and tunnelling across to the left; (iii) venoplasty facilitated CRT upgrade; (iv) lead extraction of the functional RV lead for recanalization and upgrade; (v) surgical epicardial lead placement; and (vi) a conservative approach. After careful discussion, the patient elected to proceed with an upgrade strategy (including venoplasty and lead extraction). An epicardial approach was felt too high risk given his co-morbidities.\nAs a centre with experience in HBP, and in alignment with recent guidelines, we targeted CRT-P via this approach. The least aggressive strategy was preferable and therefore prior to opening the left-sided pocket, the SCV occlusion was probed in a retrograde manner using a multipurpose catheter (6F MPA1 Impulse, Boston Scientific, MA, USA) from right femoral venous access (secured for temporary pacing wire support). In doing so, we were able to direct the catheter to the brachio-cephalic vein and define the occlusion in detail. Furthermore, contrast highlighted a large collateral branch, which we felt could be punctured directly from a left sub-clavicular approach (see , ). We left a 0.035 in J-wire in this branch, and successfully secured venous access through the Seldinger technique (see , ). A passive lead to the right atrial appendage was implanted and a 69 cm Select Secure 3830 lead (Medtronic Inc., MN, USA) was deployed via a C315 sheath (Medtronic) at the His-bundle. Final lead positions are shown in .\nIntracardiac electrograms confirmed underlying complete AV dissociation with an intrinsic His-QRSend interval of 192 ms. With HBP, non-selective capture was achieved resulting in a shortened Stim-QRSend of 158 ms with a threshold of 1 V at 0.5 ms ( and ). The device was programmed DDD-60 with an ‘LV’ to RV delay of 60 ms, to allow protective back up RV pacing in the event of loss of His capture. There were no complications and post procedural 12-lead ECG confirmed non-selective His capture.\nAfter 2 months, the patient was NYHA I, euvolaemic and LV systolic function had normalized (LVEF >55%, see , ). Device interrogation revealed atrial pacing of 56% and HBP 99% of the time.", + "fulltext_subclaims": [ + "The patient is an 83-year-old man.", + "He has a history of third-degree AV block.", + "He has a single-chamber (RV lead) permanent pacing system.", + "The pacing system has been in situ for 9 years.", + "He was referred with worsening breathlessness (NYHA III).", + "There were no other heart failure symptoms.", + "Clinical examination revealed signs of fluid overload.", + "There was elevated jugular venous pressure.", + "There was bilateral lower leg oedema.", + "There were no murmurs on auscultation.", + "He had an ablation for cavo-tricuspid isthmus dependent flutter in 2009.", + "He has mild chronic obstructive pulmonary disease.", + "There was a remote history of alcohol excess.", + "Transthoracic echocardiography at the time of original device implantation showed preserved left ventricular systolic function (LVEF 55%).", + "Drug therapy included Ramipril 10 mg o.d.", + "Drug therapy included Spironolactone 25 mg o.d.", + "Drug therapy included Bendroflumethiazide 2.5 mg o.d.", + "Drug therapy included Simvastatin 40 mg o.d.", + "Drug therapy included Omeprazole 20 mg o.d.", + "Drug therapy included Tiotropium 18 µg o.d.", + "Drug therapy included Symbicort Turbohaler 200 µg/6 µg 1 puff BD.", + "Drug therapy included Warfarin according to internal normalized ratio.", + "Betablockers had not been commenced.", + "The reason for not commencing betablockers was concerns about airways disease.", + "There was a degree of reversibility on pulmonary functional testing.", + "Twelve-lead ECG showed sinus rhythm with AV dissociation because of RV-only pacing.", + "Device interrogation confirmed 100% RV pacing.", + "Device interrogation confirmed underlying complete AV block.", + "Device interrogation confirmed a broad escape rhythm (left bundle branch block).", + "Device interrogation confirmed QRS duration 132 ms.", + "Transthoracic echocardiography revealed a non-dilated LV.", + "Transthoracic echocardiography revealed moderately impaired systolic function (LVEF 40–45%).", + "Transthoracic echocardiography showed evidence of dyssynchrony.", + "The dyssynchrony was consistent with RV apical pacing.", + "RV function was normal.", + "Pulmonary pressures were normal.", + "There were no significant valve abnormalities.", + "The most likely diagnosis was PIC.", + "Differentials included alcohol-induced cardiomyopathy.", + "Differentials included post-ablation atrial arrhythmia.", + "Despite guideline-directed medical therapy, heart failure symptoms persisted.", + "He was offered a device upgrade to a CRT-P.", + "Options considered included a conventional LV lead.", + "Options considered included a His-bundle lead.", + "Options considered included a right atrial lead.", + "Prior to implantation, left-sided venography was performed.", + "Venography showed an occluded SCV.", + "Options considered included contralateral CRT-P implantation.", + "Options considered included implanting a right-sided RA and LV lead and tunnelling across to the left.", + "Options considered included venoplasty facilitated CRT upgrade.", + "Options considered included lead extraction of the functional RV lead for recanalization and upgrade.", + "Options considered included surgical epicardial lead placement.", + "Options considered included a conservative approach.", + "The patient elected to proceed with an upgrade strategy including venoplasty and lead extraction.", + "An epicardial approach was felt too high risk.", + "The centre had experience in HBP.", + "The upgrade strategy targeted CRT-P via HBP.", + "The least aggressive strategy was preferred.", + "Prior to opening the left-sided pocket, the SCV occlusion was probed in a retrograde manner.", + "A multipurpose catheter was used for probing.", + "The catheter was directed to the brachio-cephalic vein.", + "Contrast highlighted a large collateral branch.", + "A 0.035 in J-wire was left in the collateral branch.", + "Venous access was secured through the Seldinger technique.", + "A passive lead to the right atrial appendage was implanted.", + "A 69 cm Select Secure 3830 lead was deployed via a C315 sheath.", + "The lead was deployed at the His-bundle.", + "Intracardiac electrograms confirmed underlying complete AV dissociation.", + "Intracardiac electrograms showed an intrinsic His-QRSend interval of 192 ms.", + "Non-selective capture was achieved with HBP.", + "Stim-QRSend was 158 ms.", + "Threshold was 1 V at 0.5 ms.", + "The device was programmed DDD-60.", + "The device was programmed with an ‘LV’ to RV delay of 60 ms.", + "There were no complications.", + "Post procedural 12-lead ECG confirmed non-selective His capture.", + "After 2 months, the patient was NYHA I.", + "After 2 months, the patient was euvolaemic.", + "After 2 months, LV systolic function had normalized (LVEF >55%).", + "Device interrogation revealed atrial pacing of 56%.", + "Device interrogation revealed HBP 99% of the time." + ], + "summary": "An 84-year-old man with a right ventricular (RV) pacemaker was referred with New York Heart Association (NYHA) Class III breathlessness secondary to moderate LVSD (left ventricular ejection fraction", + "summary_subclaims": [ + "The patient is an 84-year-old man.", + "The patient has a right ventricular (RV) pacemaker.", + "The patient was referred with New York Heart Association (NYHA) Class III breathlessness.", + "The breathlessness is secondary to moderate LVSD.", + "The left ventricular ejection fraction is mentioned." + ] + }, + { + "id": "multiclinsum_test_1362_en.txt", + "fulltext": "A 65-year-old man visited our outpatient department for left calf pain and swelling.\nTwo weeks prior to presentation, he had slipped and injured his left leg. He took over-the-counter pain medication, but the pain persisted and the swelling became increasingly severe. He presented to the clinic with worsening pain that he rated at visual analog scale (VAS) 7.\nThe patient was on medication for hypertension and diabetes mellitus. He had undergone a kidney transplant in 1998 for end-stage renal disease caused by immune globulin A nephropathy.\nThe patient had no specific personal and family history.\nOn physical examination, he had a stiff, localized, oval mass with a bruise on his left upper posterior calf. During palpation, tenderness was localized to the left proximal gastrocnemius muscle. The pain was aggravated by dorsiflexion of the left ankle or weight-bearing on the left foot. He could not walk without a crutch. Neurological and peripheral vascular examinations of the left lower leg were within normal limits.\nNo laboratory examination was conducted.\nInitial diagnostic ultrasonography showed a hematoma in the left gastrocnemius muscle measuring 4.3 cm × 1.5 cm × 4.9 cm . There was no active bleeding, and the hematoma was stiff and firm with low heterogeneity. Left tibial magnetic resonance imaging confirmed rupture of the medial head of the gastrocnemius muscle, with hematoma between the medial and lateral heads .", + "fulltext_subclaims": [ + "A 65-year-old man visited our outpatient department for left calf pain and swelling.", + "Two weeks prior to presentation, he had slipped and injured his left leg.", + "He took over-the-counter pain medication.", + "The pain persisted and the swelling became increasingly severe.", + "He presented to the clinic with worsening pain that he rated at visual analog scale (VAS) 7.", + "The patient was on medication for hypertension and diabetes mellitus.", + "He had undergone a kidney transplant in 1998 for end-stage renal disease caused by immune globulin A nephropathy.", + "The patient had no specific personal and family history.", + "On physical examination, he had a stiff, localized, oval mass with a bruise on his left upper posterior calf.", + "During palpation, tenderness was localized to the left proximal gastrocnemius muscle.", + "The pain was aggravated by dorsiflexion of the left ankle or weight-bearing on the left foot.", + "He could not walk without a crutch.", + "Neurological and peripheral vascular examinations of the left lower leg were within normal limits.", + "No laboratory examination was conducted.", + "Initial diagnostic ultrasonography showed a hematoma in the left gastrocnemius muscle measuring 4.3 cm × 1.5 cm × 4.9 cm.", + "There was no active bleeding.", + "The hematoma was stiff and firm with low heterogeneity.", + "Left tibial magnetic resonance imaging confirmed rupture of the medial head of the gastrocnemius muscle.", + "There was hematoma between the medial and lateral heads." + ], + "summary": "A 65-year-old man visited the outpatient department for left calf pain with swelling that had persisted since he slipped two weeks prior. The calf pain had persisted and was rated visual analog scale 7. On physical examination, there was a localized, stiff, ovoid mass on his left upper posterior calf. The pain was aggravated by dorsiflexion of the left ankle or weight-bearing on the left foot. Initial diagnostic ultrasonography showed a hematoma in the left gastrocnemius muscle; its texture was firm with low heterogeneity. We applied ESWT to the hematoma. His pain decreased immediately to a visual analog scale 3, and the mass was softened. The texture of the hematoma became more heterogeneous on ultrasonography. Due to planned overseas travel, he returned three months after the initial visit to report that the pain and swelling were dramatically relieved after ESWT.", + "summary_subclaims": [ + "A 65-year-old man visited the outpatient department for left calf pain with swelling that had persisted since he slipped two weeks prior.", + "The calf pain had persisted and was rated visual analog scale 7.", + "On physical examination, there was a localized, stiff, ovoid mass on his left upper posterior calf.", + "The pain was aggravated by dorsiflexion of the left ankle or weight-bearing on the left foot.", + "Initial diagnostic ultrasonography showed a hematoma in the left gastrocnemius muscle.", + "The texture of the hematoma was firm with low heterogeneity.", + "We applied ESWT to the hematoma.", + "His pain decreased immediately to a visual analog scale 3.", + "The mass was softened.", + "The texture of the hematoma became more heterogeneous on ultrasonography.", + "Due to planned overseas travel, he returned three months after the initial visit.", + "He reported that the pain and swelling were dramatically relieved after ESWT." + ] + }, + { + "id": "multiclinsum_test_436_en.txt", + "fulltext": "A Chinese boy with a medical history of eczema and obesity presented with two episodes of anasarca and hypovolemic shock.\nWhen the patient was six years old, he had coryzal symptoms for two days and a one-day history of vomiting, diarrhoea and generalised abdominal pain. His blood pressure was 85/66 mmHg and heart rate was 144 beats per minute (bpm) upon presentation at another local hospital. This progressed to hypovolaemic shock requiring admission to the paediatric intensive care unit for fluid resuscitation. Laboratory investigation showed haemoconcentration, hypoalbuminemia and renal impairment with metabolic acidosis . Echocardiogram revealed a thickened left ventricle. Blood culture yielded coagulase-negative Staphylococci, which was deemed a skin contaminant. He was treated with fluid resuscitation and a seven-day empiric course of ceftriaxone. The patient’s renal function normalised after fluid replacement and he was discharged after one week. An echocardiogram was repeated a month later, which showed normal ventricular wall thickness, structure and function.\nThe patient was well afterwards until he was eight years old. He presented with vomiting, diarrhoea, abdominal pain and a low-grade fever for one day. Again, he was admitted to another local hospital. The child became lethargic, hypotensive (76/52 mmHg), tachycardic (141 bpm), with physical signs of poor perfusion. Within 8 h of admission, a total of 3500 ml (70 mL/kg) of normal saline boluses were given but there were only transient periods of improvement and the blood pressure remained low overall. Laboratory investigation again showed haemoconcentration, hypoalbuminemia, impaired renal function and metabolic acidosis . Echocardiogram from the referring hospital showed a thickened left ventricle; the interventricular septum was 11.9 mm (Z-score + 13.34) and free wall was 14.2 mm (Z-score + 16.22).\nHis blood pressure remained unstable despite additional boluses of 3500 ml (70 mL/kg) of normal saline in total over the next 12 h. Multiple inotropic medications including dopamine, dobutamine, noradrenaline and stress dose hydrocortisone were started. He was transferred to our hospital, a tertiary referral centre, for consideration of ECMO within 24 h of admission.\nDuring the transfer, he was given a total of 11 intravenous boluses (total 21 mL) of 0.1 mg/mL adrenaline due to persistent shock. He developed pulseless electrical activities shortly after arrival to our cardiac intensive care unit and recovered after two minutes of cardiopulmonary resuscitation. Upon return of spontaneous circulation, his blood pressure was 44/37 mmHg and his heart rate was 185 bpm. Post-resuscitation echocardiogram showed poor systolic function of both ventricles with the left ventricular internal dimension at end-diastole (LVIDd) of 18.3 mm (z-score − 8.65); the intraventricular septum at end-diastole (IVSd) was 18.3 mm (z-score + 4.61); left ventricular posterior wall at end-diastole (LVPWd) was 13.4 mm (z-score + 3.95); left ventricle fractional shortening (LVFS) was 18.3%; tricuspid annular plane systolic excursion (TAPSE) was 14.3 mm (z-score − 3.60) and the left ventricular mass index was 70 g/m2 .\nEmergency central veno-arterial ECMO was immediately initiated via cannulation of the right atrium and ascending aorta, and another 5200 ml (100 mL/kg) of fluid and blood products were given over the first 12 h after ECMO was started to maintain his intravascular volume. An optimal ECMO flow was achieved at 3 L/min with a cardiac index of 2.2 L/min/m2 afterwards. His nasopharynx aspirate was positive for parainfluenza virus type 2 and stool culture was positive for Salmonella group B. Blood culture and urine culture were negative and there was no detectable urinary protein. The patient had a mildly low immunoglobulin (Ig) G level of 687 (724–1380) mg/dL, but normal IgA and IgM. Protein electrophoresis and urine immunofixation showed no monoclonal antibody peak.\nThe patient was very oedematous and developed compartment syndrome involving both lower limbs that required emergency fasciotomy. He also developed rhabdomyolysis with deranged renal function and pulmonary oedema 24 h after ECMO was initiated. Echocardiogram repeated 12 h after ECMO insertion showed reduced thickening of his left ventricular wall. The patient’s cardiac function, renal function and perfusion subsequently improved. Inotropic and ECMO support was weaned off three days after initiation. Echocardiogram four days after termination of ECMO support showed improvement of the left ventricular dimension and wall thickness and cardiac function: LVIDd was 33.4 mm (z-score − 2.63); IVSd was 6.95 mm (z-score 0.09); LVPWd was 6.62 mm (z-score 0.28); LVFS was 32.6% and the left ventricular mass was 39 g/m2 .\nAs the patient’s clinical and laboratory findings were all suggestive of ISCLS after discussion with an immunologist, montelukast 5 mg daily was started as prophylactic treatment at three weeks, and he received his first monthly immunoglobulin infusion (1 g/kg) prophylaxis two months after the initial presentation. At his subsequent follow-up appointment, he still had residual peroneal neuropathy. Echocardiogram 11 weeks later showed normal left ventricular wall thickness and a full recovery of his biventricular function. He has remained asymptomatic so far for more than 12 months at his most recent clinic follow-up.", + "fulltext_subclaims": [ + "The patient is a Chinese boy.", + "The patient has a medical history of eczema.", + "The patient has a medical history of obesity.", + "The patient had two episodes of anasarca.", + "The patient had two episodes of hypovolemic shock.", + "When the patient was six years old, he had coryzal symptoms for two days.", + "When the patient was six years old, he had a one-day history of vomiting.", + "When the patient was six years old, he had a one-day history of diarrhoea.", + "When the patient was six years old, he had a one-day history of generalised abdominal pain.", + "Upon presentation at another local hospital, the patient's blood pressure was 85/66 mmHg.", + "Upon presentation at another local hospital, the patient's heart rate was 144 beats per minute.", + "The patient was admitted to the paediatric intensive care unit.", + "The patient received fluid resuscitation.", + "The patient was treated with a seven-day empiric course of ceftriaxone.", + "The patient's renal function normalised after fluid replacement.", + "The patient was discharged after one week.", + "An echocardiogram was repeated a month later.", + "The echocardiogram showed normal ventricular wall thickness.", + "The echocardiogram showed normal ventricular structure.", + "The echocardiogram showed normal ventricular function.", + "The patient was well afterwards until he was eight years old.", + "The patient had vomiting for one day.", + "The patient had diarrhoea for one day.", + "The patient had abdominal pain for one day.", + "The patient had a low-grade fever for one day.", + "The patient was admitted to another local hospital.", + "The patient became lethargic.", + "The patient's blood pressure was 76/52 mmHg.", + "The patient's heart rate was 141 beats per minute.", + "The patient had physical signs of poor perfusion.", + "A total of 3500 ml of normal saline boluses were given within 8 h of admission.", + "The blood pressure remained low overall.", + "The patient's blood pressure remained unstable.", + "Multiple inotropic medications were started.", + "The patient was transferred to a tertiary referral centre.", + "The patient was given a total of 11 intravenous boluses of 0.1 mg/mL adrenaline.", + "The patient developed pulseless electrical activities shortly after arrival.", + "The patient recovered after two minutes of cardiopulmonary resuscitation.", + "Upon return of spontaneous circulation, the patient's blood pressure was 44/37 mmHg.", + "Upon return of spontaneous circulation, the patient's heart rate was 185 bpm.", + "Emergency central veno-arterial ECMO was immediately initiated.", + "Another 5200 ml of fluid and blood products were given over the first 12 h after ECMO was started.", + "An optimal ECMO flow was achieved at 3 L/min.", + "The patient's nasopharynx aspirate was positive for parainfluenza virus type 2.", + "The patient's stool culture was positive for Salmonella group B.", + "The patient's blood culture was negative.", + "The patient's urine culture was negative.", + "There was no detectable urinary protein.", + "The patient had a mildly low immunoglobulin G level.", + "The patient had normal immunoglobulin A.", + "The patient had normal immunoglobulin M.", + "The patient developed compartment syndrome involving both lower limbs.", + "The patient required emergency fasciotomy.", + "The patient developed rhabdomyolysis.", + "The patient had deranged renal function.", + "The patient had pulmonary oedema.", + "Echocardiogram repeated 12 h after ECMO insertion showed reduced thickening of the left ventricular wall.", + "The patient's cardiac function improved.", + "The patient's renal function improved.", + "The patient's perfusion improved.", + "Inotropic and ECMO support was weaned off three days after initiation.", + "Echocardiogram four days after termination of ECMO support showed improvement of the left ventricular dimension.", + "Echocardiogram four days after termination of ECMO support showed improvement of the left ventricular wall thickness.", + "Echocardiogram four days after termination of ECMO support showed improvement of cardiac function.", + "Montelukast 5 mg daily was started as prophylactic treatment.", + "The patient received his first monthly immunoglobulin infusion.", + "The patient still had residual peroneal neuropathy.", + "Echocardiogram 11 weeks later showed normal left ventricular wall thickness.", + "Echocardiogram 11 weeks later showed full recovery of biventricular function.", + "The patient has remained asymptomatic for more than 12 months." + ], + "summary": "A Chinese boy had his first attack of severe hypovolaemic shock that responded to fluid resuscitation when he was 6 years of age. His second attack developed at 8 years of age. He was then transferred to our cardiac unit for refractory hypotensive shock. The patient's echocardiogram revealed ventricular wall thickening with significant cardiac dysfunction requiring extracorporeal membrane oxygenation support. Subsequently, he made a full recovery, including his myocardial wall thickness and function. The echocardiographic findings suggested myocardial oedema that was transient in nature. Clinical and laboratory investigation from both episodes were compatible with ISCLS.", + "summary_subclaims": [ + "The patient is a Chinese boy.", + "He had his first attack of severe hypovolaemic shock when he was 6 years of age.", + "The first attack responded to fluid resuscitation.", + "He had a second attack at 8 years of age.", + "He was transferred to our cardiac unit for refractory hypotensive shock.", + "The echocardiogram revealed ventricular wall thickening.", + "The echocardiogram showed significant cardiac dysfunction.", + "Extracorporeal membrane oxygenation support was required.", + "He made a full recovery.", + "The echocardiographic findings suggested myocardial oedema.", + "The myocardial oedema was transient in nature.", + "Clinical and laboratory investigation from both episodes were compatible with ISCLS." + ] + }, + { + "id": "multiclinsum_test_3068_en.txt", + "fulltext": "We present the case of a 59-year-old woman with a history of heavy smoking and hypertension, but no relevant cardiovascular history. Her condition started twenty days ago, characterised by chest pain, dyspnoea and fever. Based on the clinical presentation, acute community-acquired pneumonia was suspected and empirical antibiotic treatment was initiated. Although the fever and chest pain had subsided, dyspnoea persisted for another fifteen days, which led her to consult again at the nearest hospital, where an electrocardiogram (ECG) revealed poor progression of R in the precordial leads, ST elevation and negative T waves. The transthoracic echocardiogram showed a severely depressed ejection fraction with apical akinesia with associated apical thrombus. With these findings, an evolved acute myocardial infarction was diagnosed and a differential diagnosis between an aneurysm with apical thrombus and a pseudoaneurysm secondary to a cardiac rupture was raised. The patient was transferred to our hospital for further evaluation and possible intervention. On admission, she was haemodynamically stable and showed no signs of low output or heart failure. Blood tests were normal. The coronary angiography that revealed an occlusion in the mid-portion of the descending anterior aorta with TIMI 0 flow and no development of collateral circulation. The remaining coronary arteries showed no other significant lesions. Subsequently, for a better anatomical understanding, a cardiac magnetic resonance (MRI) and cardiac computed tomography (CT) were performed that demonstrated severe left ventricular dysfunction, subacute infarction in the territory of the descending anterior aorta and a rupture of the left ventricular free wall with an apical thrombus containing a thrombus, which exhibited partial fragmentation in the strictly apical region. Based on these findings, the possibility of surgical intervention was evaluated, but the chest X-ray revealed severe emphysema and pulmonary function tests showed severe obstructive ventilatory impairment. For this reason, an interdisciplinary discussion was held, exploring the options of surgical repair or heart transplantation. For surgical repair with a patch (Dor procedure), it was considered that the remaining cardiac volumes would be insufficient. On the other hand, it was considered risky and probably futile to perform a heart transplantation in a patient with severe chronic obstructive pulmonary disease. Therefore, in a joint decision with the patient, it was decided to opt only for medical treatment. Nine months after diagnosis, she remains asymptomatic.\n", + "fulltext_subclaims": [ + "The patient is a 59-year-old woman.", + "She has a history of heavy smoking.", + "She has a history of hypertension.", + "She has no relevant cardiovascular history.", + "Her condition started twenty days ago.", + "The condition was characterised by chest pain.", + "The condition was characterised by dyspnoea.", + "The condition was characterised by fever.", + "Acute community-acquired pneumonia was suspected.", + "Empirical antibiotic treatment was initiated.", + "The fever had subsided.", + "The chest pain had subsided.", + "Dyspnoea persisted for another fifteen days.", + "An electrocardiogram (ECG) revealed poor progression of R in the precordial leads.", + "An electrocardiogram (ECG) revealed ST elevation.", + "An electrocardiogram (ECG) revealed negative T waves.", + "The transthoracic echocardiogram showed a severely depressed ejection fraction.", + "The transthoracic echocardiogram showed apical akinesia.", + "The transthoracic echocardiogram showed an apical thrombus.", + "An evolved acute myocardial infarction was diagnosed.", + "A differential diagnosis between an aneurysm with apical thrombus and a pseudoaneurysm secondary to a cardiac rupture was raised.", + "The patient was transferred to our hospital.", + "On admission, she was haemodynamically stable.", + "On admission, she showed no signs of low output.", + "On admission, she showed no signs of heart failure.", + "Blood tests were normal.", + "The coronary angiography revealed an occlusion in the mid-portion of the descending anterior aorta.", + "The coronary angiography revealed TIMI 0 flow.", + "The coronary angiography revealed no development of collateral circulation.", + "The remaining coronary arteries showed no other significant lesions.", + "A cardiac magnetic resonance (MRI) was performed.", + "A cardiac computed tomography (CT) was performed.", + "The MRI and CT demonstrated severe left ventricular dysfunction.", + "The MRI and CT demonstrated subacute infarction in the territory of the descending anterior aorta.", + "The MRI and CT demonstrated a rupture of the left ventricular free wall.", + "The MRI and CT demonstrated an apical thrombus.", + "The apical thrombus exhibited partial fragmentation in the strictly apical region.", + "The possibility of surgical intervention was evaluated.", + "The chest X-ray revealed severe emphysema.", + "Pulmonary function tests showed severe obstructive ventilatory impairment.", + "An interdisciplinary discussion was held.", + "The options of surgical repair or heart transplantation were explored.", + "Surgical repair with a patch (Dor procedure) was considered.", + "It was considered that the remaining cardiac volumes would be insufficient for the Dor procedure.", + "It was considered risky and probably futile to perform a heart transplantation in a patient with severe chronic obstructive pulmonary disease.", + "A joint decision with the patient was made to opt only for medical treatment.", + "Nine months after diagnosis, she remains asymptomatic." + ], + "summary": "A 59-year-old woman with no significant cardiovascular history presented with chest pain, dyspnoea and fever. She was diagnosed with acute community-acquired pneumonia and received antibiotic treatment. Due to persistence of symptoms she returned for further evaluation and an electrocardiogram revealed signs of evolving infarction. An echocardiogram revealed severely depressed ejection fraction and apical acinesia with associated thrombus. The differential diagnosis of an infarction with apical aneurysm versus a pseudoaneurisma from external cardiac rupture was raised, so she was referred to our center for further evaluation. Coronary angiography revealed occlusion in the anterior descending artery, without other significant lesions. MRI and CT confirmed severe left ventricular dysfunction with a subacute infarction and apical pseudoaneurisma with a thrombotic fragment. Surgical resolution was considered unfeasible as the CT revealed emphysema and pulmonary function tests showed severe obstructive ventilatory impairment. In agreement with the patient, it was decided to continue with medical treatment. Nine months later, she remains asymptomatic.\n", + "summary_subclaims": [ + "The patient is a 59-year-old woman.", + "She had no significant cardiovascular history.", + "She presented with chest pain, dyspnoea and fever.", + "She was diagnosed with acute community-acquired pneumonia.", + "She received antibiotic treatment.", + "She returned for further evaluation due to persistence of symptoms.", + "An electrocardiogram revealed signs of evolving infarction.", + "An echocardiogram revealed severely depressed ejection fraction.", + "An echocardiogram revealed apical acinesia.", + "An echocardiogram revealed a thrombus.", + "The differential diagnosis of an infarction with apical aneurysm versus a pseudoaneurisma from external cardiac rupture was raised.", + "She was referred to the center for further evaluation.", + "Coronary angiography revealed occlusion in the anterior descending artery.", + "MRI confirmed severe left ventricular dysfunction.", + "MRI confirmed subacute infarction.", + "MRI confirmed apical pseudoaneurisma.", + "MRI confirmed a thrombotic fragment.", + "Surgical resolution was considered unfeasible.", + "CT revealed emphysema.", + "Pulmonary function tests showed severe obstructive ventilatory impairment.", + "It was decided to continue with medical treatment.", + "Nine months later, she remains asymptomatic." + ] + }, + { + "id": "multiclinsum_test_1150_en.txt", + "fulltext": "We present a case report of a 78-year-old white man with alcoholic cirrhosis and multifocal HCC with ascites and portosystemic encephalopathy. In his past history (2 years before) he had a wedge resection of segment II for HCC (G2). Since then he was followed-up annually, including a computed tomography (CT) scan, by our medical department. He was not considered for LT due his advanced age. He presented to our emergency room for ascitic decompensation with abdominal tension and lower limb edema. During his recovery, his hematocrit suddenly dropped (hemoglobin from 9.3 g/L to 6.7 g/L in 3 hours); an abdominal CT scan showed multiple and bilateral foci of HCC with evidence of acute bleeding from one of them . His Model for End-Stage Liver Disease (MELD) score was 19; his Child–Pugh score was C11; total bilirubin was 8 mg/dl and alpha-fetoprotein (AFP) 604 ug/L. He was hemodynamically unstable and compromised so he was urgently transferred to our operating room (OR) for hemorrhagic shock. A middle line laparotomy was performed and a massive hemoperitoneum was found (4 L). His liver was cirrhotic with recanalization of umbilical vein and collateral vessels. His liver was completely subverted by a tumor and there was bleeding from two lacerations on segments II and IV, which was uncontrollable with conventional hemostatic techniques (argon beam, oxidized regenerated cellulose, and fibrin glue). Due to his condition, his poor liver function reserve, and the multifocal tumor it was decided to carry out the coagulation of the multiple vascular afferents of each single mass by RFA. Multiple RFA cycles were performed circumferentially on both nodules for a total of 40 minutes. Hemostasis was achieved; the RFA controlled the bleeding from our patient’s ruptured HCC . Operation time was 90 minutes. During the operation he needed transfusions of three packed red blood cells (PRBC) transfusions and drug support with noradrenaline 0.4 gamma/Kg/minute and dopamine 2 gamma/kg/minute. He was transferred to our intensive care unit (ICU) for postoperative monitoring. On postoperative day (POD) 2 he was discharged and reassigned to our medical floor, without vasopressor therapy. His peak postoperative transaminase levels were aspartate aminotransferase (AST) 659 UI/L and alanine aminotransferase (ALT) 260 UI/L but he did not develop liver failure. The main problem was the hepatorenal syndrome that occurred on POD9 due to the progression of his underlying liver disease; he did not need renal replacement therapy. He was discharged from our medical department; his general condition was satisfactory. He was followed-up in our clinic by our palliative care team, but unfortunately he died 2 months later due to a progression of his disease.", + "fulltext_subclaims": [ + "The patient is a 78-year-old white man.", + "He has alcoholic cirrhosis.", + "He has multifocal HCC.", + "He has ascites.", + "He has portosystemic encephalopathy.", + "In his past history (2 years before), he had a wedge resection of segment II for HCC (G2).", + "He was followed-up annually, including a computed tomography (CT) scan, by our medical department.", + "He was not considered for LT due to his advanced age.", + "He presented to our emergency room for ascitic decompensation.", + "His hematocrit suddenly dropped (hemoglobin from 9.3 g/L to 6.7 g/L in 3 hours).", + "An abdominal CT scan showed multiple and bilateral foci of HCC.", + "There was evidence of acute bleeding from one of the HCC foci.", + "His MELD score was 19.", + "His Child–Pugh score was C11.", + "His total bilirubin was 8 mg/dl.", + "His alpha-fetoprotein (AFP) was 604 ug/L.", + "He was hemodynamically unstable.", + "He was urgently transferred to our operating room (OR) for hemorrhagic shock.", + "A middle line laparotomy was performed.", + "A massive hemoperitoneum was found (4 L).", + "His liver was cirrhotic with recanalization of umbilical vein and collateral vessels.", + "His liver was completely subverted by a tumor.", + "There was bleeding from two lacerations on segments II and IV.", + "The bleeding was uncontrollable with conventional hemostatic techniques.", + "It was decided to carry out the coagulation of the multiple vascular afferents of each single mass by RFA.", + "Multiple RFA cycles were performed circumferentially on both nodules for a total of 40 minutes.", + "The RFA controlled the bleeding from our patient’s ruptured HCC.", + "Operation time was 90 minutes.", + "He needed transfusions of three packed red blood cells (PRBC) transfusions.", + "He received drug support with noradrenaline 0.4 gamma/Kg/minute and dopamine 2 gamma/kg/minute.", + "He was transferred to our intensive care unit (ICU) for postoperative monitoring.", + "On postoperative day (POD) 2 he was discharged and reassigned to our medical floor.", + "He did not receive vasopressor therapy after discharge.", + "His peak postoperative transaminase levels were aspartate aminotransferase (AST) 659 UI/L and alanine aminotransferase (ALT) 260 UI/L.", + "He did not develop liver failure.", + "The main problem was the hepatorenal syndrome that occurred on POD9.", + "The hepatorenal syndrome was due to the progression of his underlying liver disease.", + "He did not need renal replacement therapy.", + "He was discharged from our medical department.", + "His general condition was satisfactory.", + "He was followed-up in our clinic by our palliative care team.", + "He died 2 months later due to a progression of his disease." + ], + "summary": "We present a case report of a 78-year-old white man with alcoholic-related cirrhosis and a multifocal hepatocellular carcinoma. An abdominal computed tomography scan showed multiple and bilateral foci of bleeding from broken liver cancer. He was urgently transferred from our radiology unit to our operating room for massive hemoperitoneum. A middle line laparotomy detected a massive hemoperitoneum. His liver was cirrhotic and completely subverted by a tumor; there were two spontaneous bleeding lacerations on segments II and IV, which were uncontrollable with conventional hemostatic techniques. Therefore, it was decided to carry out the coagulation of the multiple vascular afferents of each single mass by means of radiofrequency ablation cycles performed circumferentially on both nodules for a total of 40 minutes. Hemostasis was achieved; the radiofrequency ablation controlled the bleeding from his ruptured hepatocellular carcinoma. He was transferred to our intensive care unit for postoperative monitoring in terms of hemodynamic stability. On postoperative day 2 he was discharged from our intensive care unit.", + "summary_subclaims": [ + "The patient was a 78-year-old white man.", + "The patient had alcoholic-related cirrhosis.", + "The patient had a multifocal hepatocellular carcinoma.", + "An abdominal computed tomography scan showed multiple and bilateral foci of bleeding from broken liver cancer.", + "The patient was urgently transferred from the radiology unit to the operating room for massive hemoperitoneum.", + "A middle line laparotomy detected a massive hemoperitoneum.", + "The liver was cirrhotic and completely subverted by a tumor.", + "There were two spontaneous bleeding lacerations on segments II and IV.", + "The bleeding lacerations were uncontrollable with conventional hemostatic techniques.", + "It was decided to carry out the coagulation of the multiple vascular afferents of each single mass by means of radiofrequency ablation cycles.", + "Radiofrequency ablation cycles were performed circumferentially on both nodules for a total of 40 minutes.", + "Hemostasis was achieved.", + "The radiofrequency ablation controlled the bleeding from the ruptured hepatocellular carcinoma.", + "The patient was transferred to the intensive care unit for postoperative monitoring in terms of hemodynamic stability.", + "On postoperative day 2, the patient was discharged from the intensive care unit." + ] + }, + { + "id": "multiclinsum_test_3229_en.txt", + "fulltext": "A 25-month-old boy was referred to our outpatient clinic without complaints due to a prenatal ultrasound that showed renal cysts. The patient was already on antibiotic prophylaxis and his physical examination and vital signs were within normal limits. The parents reported no family history of renal disease and/or other hereditary disorders. A renal ultrasound performed at 2 days of life showed bilateral hydronephrosis, mainly in the right kidney. At 5 months of age, a DTPA and a DMSA were performed. The DTPA showed strong retention of the marker in the pyelocaliceal system bilaterally, with little response to diuretic challenge, while the DMSA indicated preserved renal function and symmetrical distribution of the radiotracer in the kidneys with relative renal function of 46% in the left kidney and 54% in the right kidney.\n\nBased on the first consultation in our clinic, the antibiotic prophylaxis was maintained and a new renal ultrasound was requested, which showed dilation in the entire length of both ureters (10 mm on the right side and 8 mm on the left side), with an abrupt stenosis in the distal region of both ureters at the entrance to the bladder, with a caliber of only 2 mm. In addition, moderate bilateral hydronephrosis and slight thinning of the cortical renal parenchyma were also observed. These findings indicated the diagnosis of bilateral megaureter secondary to stenosis caused by OJVU and vesicoureteral reflux (RVU). At 2 years and 10 months of age, a DTPA and a DMSA were requested. The DTPA showed obstructive pyelocaliceal and urethral stasis in both kidneys, with a scintigraphic pattern consistent with bilateral hydronephrosis secondary to stasis at the level of the JVU with preservation of renal function. Despite the observed dilation, the parenchyma and the renal cortex were preserved and the DTPA pattern showed a degree of slow emptying, while the DMSA showed that the relative renal function remained stable at 46:54.\n\nBased on clinical and imaging findings, non-surgical management was adopted with clinical follow-up and serial imaging. During the first year, the patient visited the outpatient clinic every 6 months and in the following 2 years, annually. At 7 years and 7 months, the antibiotic prophylaxis was discontinued, with no history of urinary tract infections, and follow-up visits were maintained every 2 years. Renal ultrasound at 10 years of age showed significant improvement of all parameters with ureteral transverse diameter exhibiting a mild to moderate increase (0.9 cm) and JVU preserved, indicating satisfactory evolution and bilateral renal development expected with the non-surgical approach. During the entire follow-up period, the patient remained normotensive, with normal serum levels of urea and creatinine, and without proteinuria, indicating a favorable clinical evolution.\n", + "fulltext_subclaims": [ + "The patient was referred to the outpatient clinic without complaints.", + "The referral was due to a prenatal ultrasound that showed renal cysts.", + "The patient was already on antibiotic prophylaxis.", + "The physical examination and vital signs were within normal limits.", + "The parents reported no family history of renal disease.", + "A renal ultrasound performed at 2 days of life showed bilateral hydronephrosis.", + "The hydronephrosis was mainly in the right kidney.", + "A DTPA and a DMSA were performed at 5 months of age.", + "The DTPA showed strong retention of the marker in the pyelocaliceal system bilaterally.", + "The DTPA showed little response to diuretic challenge.", + "The DMSA indicated preserved renal function.", + "The DMSA showed symmetrical distribution of the radiotracer in the kidneys.", + "The relative renal function was 46% in the left kidney.", + "The relative renal function was 54% in the right kidney.", + "A new renal ultrasound showed dilation in the entire length of both ureters.", + "The right ureter had a transverse diameter of 10 mm.", + "The left ureter had a transverse diameter of 8 mm.", + "There was an abrupt stenosis in the distal region of both ureters at the entrance to the bladder.", + "The stenosis had a caliber of only 2 mm.", + "Moderate bilateral hydronephrosis was observed.", + "Slight thinning of the cortical renal parenchyma was observed.", + "The diagnosis was bilateral megaureter secondary to stenosis caused by OJVU.", + "The diagnosis also included vesicoureteral reflux.", + "A DTPA and a DMSA were requested at 2 years and 10 months of age.", + "The DTPA showed obstructive pyelocaliceal and urethral stasis in both kidneys.", + "The DTPA pattern was consistent with bilateral hydronephrosis secondary to stasis at the level of the JVU.", + "The DTPA showed preservation of renal function.", + "The DTPA showed a degree of slow emptying.", + "The DMSA showed that the relative renal function remained stable at 46:54.", + "Non-surgical management was adopted.", + "Clinical follow-up and serial imaging were part of the management.", + "The patient visited the outpatient clinic every 6 months during the first year.", + "The patient visited the outpatient clinic annually during the following 2 years.", + "Antibiotic prophylaxis was discontinued at 7 years and 7 months.", + "There was no history of urinary tract infections.", + "Follow-up visits were maintained every 2 years.", + "Renal ultrasound at 10 years of age showed significant improvement of all parameters.", + "The ureteral transverse diameter exhibited a mild to moderate increase (0.9 cm).", + "JVU was preserved.", + "The patient remained normotensive during the entire follow-up period.", + "Serum levels of urea and creatinine were normal.", + "There was no proteinuria.", + "The clinical evolution was favorable." + ], + "summary": "A 25-month-old boy was referred without complaints for consultation due to a prenatal ultrasound that showed kidneys with cysts. He was on anti-biotic prophylaxis. No family history of renal disease and/or hereditary disorders was reported. A renal ultrasound (USR) at 2 days of life showed bilateral hydronephrosis, thus ruling out the possibility of cystic renal disease. Dynamic renal scintigraphy (DTPA) showed a marked retention of the tracer in the pyelocaliceal system bilaterally, with little response to the diuretic. The patient was kept on anti-biotic prophylaxis, when a new USR showed bilateral ureteral dilatation, abrupt stenosis in the transitional region ureterovesical (calibre 0.2 cm), moderate bilateral hydronephrosis and mild renal cortical thickening, confirming the diagnosis of OJVU. At 2 years and 10 months of age, the DTPA showed bilateral hydronephrosis and ureteral stasis in both kidneys secondary to stenosis at the level of the vesicoureteral junction (JVU), with preservation of renal function and slow grade of emptying. We opted for a non-surgical approach. A USR at 10 years of age showed significant improvement of all parameters, with transverse ureteral diameter of 9 mm, JVU preserved, and bilateral renal development appropriate to age.\n", + "summary_subclaims": [ + "A 25-month-old boy was referred without complaints for consultation due to a prenatal ultrasound that showed kidneys with cysts.", + "He was on anti-biotic prophylaxis.", + "No family history of renal disease and/or hereditary disorders was reported.", + "A renal ultrasound at 2 days of life showed bilateral hydronephrosis.", + "The ultrasound ruled out the possibility of cystic renal disease.", + "Dynamic renal scintigraphy showed a marked retention of the tracer in the pyelocaliceal system bilaterally.", + "The tracer showed little response to the diuretic.", + "A new ultrasound showed bilateral ureteral dilatation.", + "The ultrasound showed abrupt stenosis in the transitional region ureterovesical.", + "The ultrasound showed moderate bilateral hydronephrosis.", + "The ultrasound showed mild renal cortical thickening.", + "The ultrasound confirmed the diagnosis of OJVU.", + "At 2 years and 10 months of age, DTPA showed bilateral hydronephrosis.", + "The DTPA showed ureteral stasis in both kidneys secondary to stenosis at the level of the vesicoureteral junction.", + "The DTPA showed preservation of renal function.", + "The DTPA showed a slow grade of emptying.", + "A non-surgical approach was opted for.", + "A USR at 10 years of age showed significant improvement of all parameters.", + "The USR showed a transverse ureteral diameter of 9 mm.", + "The USR showed JVU preserved.", + "The USR showed bilateral renal development appropriate to age." + ] + }, + { + "id": "multiclinsum_test_3136_en.txt", + "fulltext": "A 69-year-old male patient presented to our cardiology clinic complaining of intermittent shortness of breath upon moderate exertion in the absence of chest pain, paroxysmal nocturnal dyspnea, orthopnea, dizziness, palpitations, or lower limb edema for a couple of months. The patient’s past medical history was significant because of a history of pericarditis associated with pericardial effusion 6 years prior to his presentation at our clinic, which was resolved with appropriate pharmacological treatment consisting of NSAIDs and colchicine and of which he had not complained since. Also, he had an anterior wall myocardial infarction dating to several years ago, which required immediate intervention and stenting to his left anterior descending artery. Additionally, the patient is a heavy smoker and is diabetic, and hypertensive, both conditions are under pharmacological intervention and well-controlled.\n\nAt first visit, the patient’s results were as follows: blood pressure 131/67 mmHg, heart rate 85 bpm, respiratory rate 18bpm, oxygen saturation rate 95%, and oral temperature 36.5 C. A cardiopulmonary examination showed normal S1 and S2 with no murmurs and clear lung fields to auscultation bilaterally. Laboratory tests included negative outcomes for tuberculosis, ANA, and rheumatoid factor double-stranded DNA thus making any rheumatological disease less likely. ECG showed a sinus rhythm with q waves in the anteroseptal leads. Subsequently a transthoracic echocardiogram (TTE) was performed and revealed an ejection fraction of 60%, no wall motion abnormality and mild left ventricular hypertrophy. Additional findings noted were grade 1 diastolic dysfunction, moderate aortic stenosis, mild aortic regurgitation and a moderate pericardial effusion moderately circumferential with an anterior pocket of 1 cm and a posterior pocket of 1.8–2.4 cm with no evidence of cardiac tamponade physiology. At that point, the patient was prescribed colchicine for 3 months and NSAIDS for 14 days with a follow-up visit. Then the patient improved, and his pericardial effusion improved.\n\nThree months following his initial presentation, the patient started complaining again of occasional symptoms of chest pain not related to physical activity or stress. However, the patient reported that his shortness of breath had diminished with time. Based on this clinical picture, the possibility of coronary artery syndrome was suspected and needed to be ruled out. The patient underwent a pharmacological myocardial perfusion stress and rest scan. The test showed no significant evidence of ischemia and a subtle decrease uptake in the distal anteroseptal wall, which represents apical thinning rather than a true perfusion defect. The ECG portion of the study was normal. The patient was treated with another course of colchicine and steroids.\n\nSix months later, the patient presented with a third relapse of shortness of breath. Upon inquiring further, the patient revealed that he had, unfortunately, discontinued the colchicine prior to completing the intended period of six months. TTE showed relapse of pericardial effusion and an echo-dense lesion in the pericardium of the anterior wall, which was more prominent than had been seen on the previous echo. This led to performing a CMR, which revealed an echo-dense lesion in the pericardium of the anterior wall between the right atrium and the right ventricle. It was accompanied by moderate pericardial effusion consisting of multiple layered fibrous bands that were more pronounced at the right ventricle, with a maximum thickness of 26mm and the appearances of fibrotic pericarditis (non-constrictive pericarditis) with delayed enhancement. Accordingly, the diagnosis of a fibrous pericardial mass was established. The patient was treated with a prolonged course of colchicine.", + "fulltext_subclaims": [ + "The patient is a 69-year-old male.", + "The patient presented with intermittent shortness of breath upon moderate exertion.", + "The patient had no chest pain.", + "The patient had no paroxysmal nocturnal dyspnea.", + "The patient had no orthopnea.", + "The patient had no dizziness.", + "The patient had no palpitations.", + "The patient had no lower limb edema.", + "The patient had a history of pericarditis associated with pericardial effusion 6 years prior.", + "The pericarditis was resolved with NSAIDs and colchicine.", + "The patient had an anterior wall myocardial infarction several years ago.", + "The myocardial infarction required stenting to the left anterior descending artery.", + "The patient is a heavy smoker.", + "The patient is diabetic.", + "The patient is hypertensive.", + "The patient’s diabetes and hypertension are under pharmacological intervention.", + "The patient’s diabetes and hypertension are well-controlled.", + "The patient’s blood pressure was 131/67 mmHg.", + "The patient’s heart rate was 85 bpm.", + "The patient’s oxygen saturation rate was 95%.", + "The patient’s oral temperature was 36.5 C.", + "The cardiopulmonary examination showed normal S1 and S2.", + "The cardiopulmonary examination showed no murmurs.", + "The cardiopulmonary examination showed clear lung fields bilaterally.", + "Laboratory tests showed negative tuberculosis.", + "Laboratory tests showed negative ANA.", + "Laboratory tests showed negative rheumatoid factor double-stranded DNA.", + "The ECG showed sinus rhythm.", + "The ECG showed q waves in the anteroseptal leads.", + "The TTE showed an ejection fraction of 60%.", + "The TTE showed no wall motion abnormality.", + "The TTE showed mild left ventricular hypertrophy.", + "The TTE showed grade 1 diastolic dysfunction.", + "The TTE showed moderate aortic stenosis.", + "The TTE showed mild aortic regurgitation.", + "The TTE showed a moderate pericardial effusion.", + "The pericardial effusion was moderately circumferential.", + "The anterior pocket of the pericardial effusion was 1 cm.", + "The posterior pocket of the pericardial effusion was 1.8–2.4 cm.", + "There was no evidence of cardiac tamponade physiology.", + "The patient was prescribed colchicine for 3 months.", + "The patient was prescribed NSAIDs for 14 days.", + "The patient had a follow-up visit.", + "The patient improved.", + "The pericardial effusion improved.", + "Three months later, the patient started complaining of occasional chest pain.", + "The chest pain was not related to physical activity.", + "The chest pain was not related to stress.", + "The patient reported that his shortness of breath had diminished.", + "The possibility of coronary artery syndrome was suspected.", + "The patient underwent a pharmacological myocardial perfusion stress and rest scan.", + "The scan showed no significant evidence of ischemia.", + "The scan showed a subtle decrease uptake in the distal anteroseptal wall.", + "The subtle decrease uptake represented apical thinning.", + "The ECG portion of the study was normal.", + "The patient was treated with another course of colchicine.", + "The patient was treated with another course of steroids.", + "Six months later, the patient presented with a third relapse of shortness of breath.", + "The patient had discontinued colchicine prior to completing the intended period of six months.", + "The TTE showed relapse of pericardial effusion.", + "The TTE showed an echo-dense lesion in the pericardium of the anterior wall.", + "The echo-dense lesion was more prominent than previously seen.", + "A CMR was performed.", + "The CMR showed an echo-dense lesion in the pericardium of the anterior wall between the right atrium and the right ventricle.", + "The CMR showed moderate pericardial effusion consisting of multiple layered fibrous bands.", + "The fibrous bands were more pronounced at the right ventricle.", + "The maximum thickness of the fibrous bands was 26mm.", + "The CMR showed appearances of fibrotic pericarditis.", + "The CMR showed non-constrictive pericarditis.", + "The CMR showed delayed enhancement.", + "The diagnosis of a fibrous pericardial mass was established.", + "The patient was treated with a prolonged course of colchicine." + ], + "summary": "A 69-year-old patient presented to our cardiology clinic complaining of intermittent shortness of breath upon moderate exertion in the absence of chest pain, paroxysmal nocturnal dyspnea, orthopnea, dizziness, palpitations, or lower limb edema. The patient's past medical history was significant because of his history of pericarditis associated with pericardial effusion 6 years prior to presentation at our clinic. Despite adequate medical treatment, the patient complained of a relapsing and remitting pattern of symptoms that mandated the performance of advanced cardiovascular imaging, namely, cardiac magnetic resonance imaging, which revealed the presence of a profound pericardial mass.", + "summary_subclaims": [ + "The patient is a 69-year-old.", + "The patient presented to the cardiology clinic.", + "The patient complained of intermittent shortness of breath upon moderate exertion.", + "The patient had no chest pain.", + "The patient had no paroxysmal nocturnal dyspnea.", + "The patient had no orthopnea.", + "The patient had no dizziness.", + "The patient had no palpitations.", + "The patient had no lower limb edema.", + "The patient's past medical history was significant for pericarditis associated with pericardial effusion 6 years prior to presentation.", + "The patient had a relapsing and remitting pattern of symptoms.", + "The patient underwent cardiac magnetic resonance imaging.", + "The imaging revealed the presence of a profound pericardial mass." + ] + }, + { + "id": "multiclinsum_test_1962_en.txt", + "fulltext": "An 80-year-old woman was admitted to the emergency department of our hospital with dyspnea and without other respiratory symptoms or fever. She had back pain, which started 1 week before admission, radiating in the right knee. She had similar complaints a year before, due to a herniated disc. The patient’s past medical history included triple-negative, node-positive cancer of the right breast (cT3 cN1 cM0 G2, estrogen receptor- and progesterone receptor-negative, HER2-negative, PD-L1-negative, BRCA-negative) diagnosed 7 months earlier. After eleven cycles of chemotherapy with paclitaxel and carboplatin, a mastectomy was performed. Subsequently, she received adjuvant chemotherapy with capecitabine and percutaneous radiotherapy of the right breast inclusive of axillary, paraclavicular and parasternal lymphatic drainage. When radiotherapy was completed, she had shortness of breath on light exertion. At admission, tachypnea was present with a respiratory rate of 24 breaths per minute and an oxygenation saturation of 89% breathing ambient air. The heart rate was 78 beats per minute, and blood pressure 160/76 mm Hg. The hemoglobin level was 11.2 g/dL, and the platelet count was 68,000/mm3. The white blood cell count was 7,400/mm3, with 79.6% neutrophils. Serum C-reactive protein was elevated (80 mg/L), and the sodium level was decreased (125 mmol/L), diagnosed as syndrome of inadequate antidiuretic hormone secretion. A pronounced D-dimer elevation (55 μg/mL) was also detected. The patient’s characteristics are summarized in .\nA CT scan with pulmonary embolism detection program of the chest revealed smooth interlobular septal thickening with centrilobular consolidation and pleural effusions, as shown in . Angiography of the greater pulmonary arteries was negative for pulmonary embolism, and there were no signs of acute right heart failure, but signs of chronic pulmonary arterial hypertension were evident. Additionally, progressive mediastinal lymphadenopathy and right mammary soft tissue thickening, highly suspicious for a locoregional recurrence of the breast cancer, were detected. Further, the CT scan showed multiple metastases and suspect sclerotic lesions in the thoracic spine.\nAdvanced tumor progression was suspected, but neither chemotherapy (due to the poor condition [ECOG 3] and low platelets) nor immunotherapy (due to low PD-L1 expression in a previous biopsy) nor an antibody-drug conjugate (due to hematotoxicity) was a causative treatment option. Symptomatic treatment for the respiratory distress consisted of oxygen, inhalation therapy with anticholinergic and beta-agonist bronchodilators, as well as oral corticosteroids. A follow-up CT scan of the chest 7 days later showed regressive pulmonary congestion. The platelets continued to decrease with a count of 22,000/mm3 7 days after admission. The patient’s condition massively deteriorated under the initiated therapy, and finally, end-of-life-care was initiated, given a situation with rapidly progressive carcinoma. The patient died 8 days after admission.\nAn autopsy was then performed, revealing numerous tumor embolisms in the small- and medium-sized pulmonary vessels, partly with associated thrombi indicating PTTM . In addition, advanced metastatic disease with manifestations in the liver, non-regional lymph nodes, visceral pleura, all vertebral bodies, both suprarenal glands, and the mucosa of the stomach was found. The histomorphology was consistent with the pre-diagnosed triple-negative breast cancer.", + "fulltext_subclaims": [ + "The patient was an 80-year-old woman.", + "She was admitted to the emergency department with dyspnea.", + "She had back pain radiating to the right knee.", + "She had similar complaints a year before due to a herniated disc.", + "The patient had triple-negative, node-positive cancer of the right breast.", + "The cancer was diagnosed 7 months earlier.", + "The cancer was BRCA-negative.", + "After eleven cycles of chemotherapy with paclitaxel and carboplatin, a mastectomy was performed.", + "She received adjuvant chemotherapy with capecitabine.", + "She received percutaneous radiotherapy of the right breast inclusive of axillary, paraclavicular, and parasternal lymphatic drainage.", + "When radiotherapy was completed, she had shortness of breath on light exertion.", + "At admission, the oxygenation saturation was 89% breathing ambient air.", + "The platelet count was 68,000/mm3.", + "The serum C-reactive protein was elevated to 80 mg/L.", + "The sodium level was decreased to 125 mmol/L, diagnosed as syndrome of inadequate antidiuretic hormone secretion.", + "A CT scan with pulmonary embolism detection program of the chest revealed smooth interlobular septal thickening.", + "Angiography of the greater pulmonary arteries was negative for pulmonary embolism.", + "The CT scan showed multiple metastases and suspect sclerotic lesions in the thoracic spine.", + "Advanced tumor progression was suspected.", + "Symptomatic treatment for the respiratory distress consisted of oxygen, inhalation therapy with anticholinergic and beta-agonist bronchodilators, and oral corticosteroids.", + "A follow-up CT scan of the chest 7 days later showed regressive pulmonary congestion.", + "The platelets continued to decrease with a count of 22,000/mm3 7 days after admission.", + "The patient’s condition massively deteriorated under the initiated therapy.", + "End-of-life care was initiated.", + "The patient died 8 days after admission.", + "An autopsy was performed.", + "The autopsy revealed numerous tumor embolisms in the small- and medium-sized pulmonary vessels.", + "The histomorphology was consistent with the pre-diagnosed triple-negative breast cancer." + ], + "summary": "An 80-year-old woman with triple-negative breast cancer was admitted to our hospital with progressive dyspnea and lower back pain. Breast cancer treatment included mastectomy, neoadjuvant and adjuvant chemotherapy as well as adjuvant radiotherapy, receiving her last cycle of radiotherapy 8 days before death. At admission, D-dimers were strongly elevated and platelets were low. NT-pro-BNP was moderately elevated. A CT scan of the chest did not show pulmonary embolism but revealed interlobular septal thickening, centrilobular consolidation, and distension of the pulmonary arteries. Moreover, new skeletal and most likely lymphatic metastasis was described. Treatment with oxygen and oral glucocorticoids was initiated, assuming radiotherapy-induced pneumonitis. Due to low expression of PD-L1 and her markedly bad performance status, tumor-specific therapy was not possible, and the treatment regimen was changed to best supportive care. The patient died 8 days after admission. Autopsy revealed numerous events consistent with tumor emboli in the pulmonary vessels, suggesting PTTM.", + "summary_subclaims": [ + "The patient was an 80-year-old woman with triple-negative breast cancer.", + "She was admitted with progressive dyspnea and lower back pain.", + "Breast cancer treatment included mastectomy.", + "Breast cancer treatment included neoadjuvant and adjuvant chemotherapy.", + "Breast cancer treatment included adjuvant radiotherapy.", + "She received her last cycle of radiotherapy 8 days before death.", + "At admission, D-dimers were strongly elevated.", + "At admission, platelets were low.", + "NT-pro-BNP was moderately elevated.", + "A CT scan of the chest did not show pulmonary embolism.", + "The CT scan revealed interlobular septal thickening.", + "The CT scan revealed centrilobular consolidation.", + "The CT scan revealed distension of the pulmonary arteries.", + "New skeletal and most likely lymphatic metastasis was described.", + "Treatment with oxygen and oral glucocorticoids was initiated.", + "Treatment was based on the assumption of radiotherapy-induced pneumonitis.", + "Due to low expression of PD-L1, tumor-specific therapy was not possible.", + "Due to markedly bad performance status, tumor-specific therapy was not possible.", + "The treatment regimen was changed to best supportive care.", + "The patient died 8 days after admission.", + "Autopsy revealed numerous events consistent with tumor emboli in the pulmonary vessels.", + "Autopsy findings suggested PTTM." + ] + }, + { + "id": "multiclinsum_test_460_en.txt", + "fulltext": "A 42-year-old male was admitted to our observation with dyspnea, temperature, abdominal discomfort and weight loss. He had previously experienced tuberculosis infection, and his past surgical history was uneventful. The physical examination confirmed epigastric and mesogastric pain. The radiological images demonstrated right fluid pleurical collection with passive collapse of the lung inferior lobe, abnormal lymph nodes of the right internal mammary chain and anterior mediastinum . At the patient admission, we had drained the right symptomatic hemothorax and sent to our pathologists the pleurical fluid for cytology exam. The patient underwent an abdominal CT scan that demonstrated a 7 cm hypodense lesion between segment V and VIII of the liver with minute calcifications, inhomogeneously hypoattenuating relative to the surrounding liver parenchyma. This lesion was surrounded by a very thin capsule showing irregular limits in the cranial portion. The right hepatic lobe showed irregular profile with the presence of diffuse lesions of 0,5-3,5 cm in length, reported along right triangular ligament and subcapsular hepatic region, suspected for hematomas. Hemoperitoneum was also documented . According to the severe clinical condition and the hemodynamic instability, the patient underwent hepatic angiography with selective catheterization of the common hepatic artery, its branches and right diaphragmatic artery. The diagnostic phase of angiography did not document any active bleeding, as well as during the selective coaxial study of the intrahepatic arterial branches of right hemi-system and right diaphragmatic artery. An exploratory laparotomy was finally proposed. At surgery, the hepatic mass, the multiple subcapsular hematomas, and the hemoperitoneum were confirmed . The liver had no signs of cirrhosis. The extemporaneous biopsy showed signs of undifferentiated carcinoma. The surgical procedure consisted in omentectomy, toilette and hemostasis of the peritoneal cavity.\nThe histological diagnosis of malignant PEComa is based on the published criteria by Folpe and co-workers. In our case, the tumor is characterized by the proliferation of epitheliod and spindle cells. The neoplastic cells are arranged in small-nests or sheet-like patterns, traversed by a delicate vasculature consisting of a rich network of sinusoid-type blood vessels. The tumor cells showed a round to oval nucleus, often with prominent nucleolus and exhibited high nuclear pleomorphism. The tumor is comprised of a population of large polyclonal cells with abundant cytoplasm. The mitotic index is elevated (> 40 figures per 50 high power fields, HPF) and the coagulative necrosis, a prominent feature, appeared as multiple foci of variable sizes. Microscopically the tumor border was infiltrative.\nFor immunohistochemistry on formalin-fixed paraffin-embedded samples, sections were treated with H2O2/3% for 5 minutes to inhibit endogenous peroxidase and then washed in H2O. Antigen was unmasked by treatment with EDTA at pH 9, or with citrate buffer at pH 6 in a microwave oven (two 5-minutes courses). The slices were then held for 20 minutes at room temperature. After washing in PBS/Tween-20, sections were incubated for 30 minutes with the primary antibodies. Then, they were washed and stained with Bond™ Polymer Refine/HRP Detection Kit according to the manufacturer's protocol (Leica, Wetzlar, Germany) or Bond™ Polymer Refine Red Detection Kit (Leica) for HMB-45 an Melan-A. For negative controls, we substituted non-immune sera for the primary antibodies. The immunohistochemistry analysis demonstrated positive staining for Vimentin (Novocastra), Melan-A (Dako), HMB-45 (Dako), smooth muscle actin (SMA) (Dako), MIB-1(Novocastra), and CD31 (Novocastra). It was negative for S-100 protein (Dako), Cytokeratin-AE1/AE3 (CKAE1/AE3) (Novocastra), Cytokeratin-5 (CK5) (Novocastra), CD30 (Dako). Based on this specific immunophenotype profile, diagnosis of PEComa was made . The multiple lesions, suspected to be lymphatic metastasis in the thorax CT images, were not confirmed by a cytology exam of pleurical fluid. Infact, the cytology analysis has documented the presence of leucocytes, red globular cells and rare mesothelial cells, but not tumor cells. It was impossible in our case to confirm histologically the suspected metastatic lesions observed along lymphatic internal right mammary chain, anterior mediastinum, aorta-lung interface and of the lung.\nThe immediate post-operative course was uneventful and the patient received supporting therapy with blood and plasma transfusions. PEComa was clinically malignant, leading to a fatal outcome in our experience.", + "fulltext_subclaims": [ + "A 42-year-old male was admitted with dyspnea, temperature, abdominal discomfort, and weight loss.", + "He had previously experienced tuberculosis infection.", + "The physical examination confirmed epigastric and mesogastric pain.", + "Radiological images demonstrated right fluid pleural collection with passive collapse of the lung inferior lobe.", + "The radiological images showed abnormal lymph nodes of the right internal mammary chain and anterior mediastinum.", + "The patient had a right symptomatic hemothorax drained at admission.", + "The pleural fluid was sent for cytology exam.", + "An abdominal CT scan demonstrated a 7 cm hypodense lesion between segment V and VIII of the liver with minute calcifications.", + "The lesion was inhomogeneously hypoattenuating relative to the surrounding liver parenchyma.", + "The lesion was surrounded by a very thin capsule showing irregular limits in the cranial portion.", + "The right hepatic lobe showed irregular profile with diffuse lesions of 0.5-3.5 cm in length.", + "The lesions were reported along the right triangular ligament and subcapsular hepatic region, suspected for hematomas.", + "Hemoperitoneum was documented.", + "The patient underwent hepatic angiography with selective catheterization of the common hepatic artery, its branches, and right diaphragmatic artery.", + "The diagnostic phase of angiography did not document any active bleeding.", + "An exploratory laparotomy was proposed.", + "At surgery, the hepatic mass, multiple subcapsular hematomas, and hemoperitoneum were confirmed.", + "The liver had no signs of cirrhosis.", + "The extemporaneous biopsy showed signs of undifferentiated carcinoma.", + "The surgical procedure consisted in omentectomy, toilette, and hemostasis of the peritoneal cavity.", + "The histological diagnosis of malignant PEComa is based on the published criteria by Folpe and co-workers.", + "The tumor is characterized by the proliferation of epithelioid and spindle cells.", + "The neoplastic cells are arranged in small-nests or sheet-like patterns, traversed by a delicate vasculature consisting of a rich network of sinusoid-type blood vessels.", + "The tumor cells showed a round to oval nucleus, often with prominent nucleolus and exhibited high nuclear pleomorphism.", + "The tumor is comprised of a population of large polyclonal cells with abundant cytoplasm.", + "The mitotic index is elevated (> 40 figures per 50 high power fields, HPF).", + "Coagulative necrosis appeared as multiple foci of variable sizes.", + "Microscopically the tumor border was infiltrative.", + "For immunohistochemistry, sections were treated with H2O2/3% for 5 minutes to inhibit endogenous peroxidase.", + "Antigen was unmasked by treatment with EDTA at pH 9, or with citrate buffer at pH 6 in a microwave oven (two 5-minute courses).", + "The slices were then held for 20 minutes at room temperature.", + "After washing in PBS/Tween-20, sections were incubated for 30 minutes with the primary antibodies.", + "They were stained with Bond™ Polymer Refine/HRP Detection Kit according to the manufacturer's protocol.", + "The immunohistochemistry analysis demonstrated positive staining for Vimentin, Melan-A, HMB-45, smooth muscle actin, MIB-1, and CD31.", + "It was negative for S-100 protein, Cytokeratin-AE1/AE3, Cytokeratin-5, and CD30.", + "Based on this specific immunophenotype profile, diagnosis of PEComa was made.", + "The multiple lesions suspected to be lymphatic metastasis in the thorax CT images were not confirmed by a cytology exam of pleural fluid.", + "The cytology analysis documented the presence of leucocytes, red globular cells, and rare mesothelial cells, but not tumor cells.", + "It was impossible to confirm histologically the suspected metastatic lesions observed along lymphatic internal right mammary chain, anterior mediastinum, aorta-lung interface, and of the lung.", + "The immediate post-operative course was uneventful.", + "The patient received supporting therapy with blood and plasma transfusions.", + "PEComa was clinically malignant, leading to a fatal outcome in our experience." + ], + "summary": "We handled the case of a 42-year-old man with unresectable PEComa of the abdomen. A 7 cm hepatic hypodense lesion between segment V and VIII of the liver and diffuse intraperitoneal nodules of 0,3-3,5 cm along the right subcapsular hepatic region, were documented by a CT scan. Radiological images showed abnormal lymph nodes of the right internal mammary chain and anterior mediastinum. The patient underwent an explorative laparotomy for uncontrolled intraabdominal hemorrhage without a well-defined preoperative tumor diagnosis. At surgery, multiple lobulated nodules containing hemorrhagic fluid on the liver surface, peritoneum and omentum were confirmed. The procedure had a palliative intent and consisted of hemostasis, hematomas evacuation and omentectomy. The diagnosis of PEComa was made after surgery on the basis of morphological and immunohistochemical criteria. Radiological and intra operative findings suggest that the mass has an hepatic origin with diffuse involvement of hepatic capsule and suspensory ligaments. The patient received medical support care with blood and plasma transfusions. In our experience, PEComa was clinically malignant, leading to a fatal outcome 25 days after hospital admission of patient.", + "summary_subclaims": [ + "The patient was a 42-year-old man.", + "The patient had unresectable PEComa of the abdomen.", + "A 7 cm hepatic hypodense lesion between segment V and VIII of the liver was documented by a CT scan.", + "Diffuse intraperitoneal nodules of 0,3-3,5 cm along the right subcapsular hepatic region were documented by a CT scan.", + "Radiological images showed abnormal lymph nodes of the right internal mammary chain.", + "Radiological images showed abnormal lymph nodes of the anterior mediastinum.", + "The patient underwent an explorative laparotomy for uncontrolled intraabdominal hemorrhage.", + "The explorative laparotomy was performed without a well-defined preoperative tumor diagnosis.", + "At surgery, multiple lobulated nodules containing hemorrhagic fluid on the liver surface were confirmed.", + "At surgery, multiple lobulated nodules containing hemorrhagic fluid on the peritoneum and omentum were confirmed.", + "The procedure had a palliative intent.", + "The procedure consisted of hemostasis.", + "The procedure consisted of hematomas evacuation.", + "The procedure consisted of omentectomy.", + "The diagnosis of PEComa was made after surgery.", + "The diagnosis of PEComa was made on the basis of morphological and immunohistochemical criteria.", + "Radiological and intra operative findings suggest that the mass has an hepatic origin.", + "Radiological and intra operative findings suggest diffuse involvement of hepatic capsule and suspensory ligaments.", + "The patient received medical support care with blood and plasma transfusions.", + "In our experience, PEComa was clinically malignant.", + "The patient had a fatal outcome 25 days after hospital admission." + ] + }, + { + "id": "multiclinsum_test_3271_en.txt", + "fulltext": "Patient background\nOur patient was a 73-year-old male diagnosed with localized prostatic cancer on a background of long-standing metabolic syndrome, osteoarthritis, peptic ulcer disease and two previous cerebrovascular accidents (CVA). His regular medications were aspirin, telmisartan, rosuvastatin, esomeprazole, empagliflozin and metformin. He had no known allergies. He was an ex-smoker and drank one bottle of wine a night.\n\nProstate cancer diagnosis\nThe patient was referred to urology with an elevated PSA of 15.4 ng/ml, which was an increase from 8.13 ng/ml performed the year prior. Multiparametric MRI (mpMRI) demonstrated no lesion and a transperineal prostate biopsy (TPB) revealed Gleason 9 (G4+5), grade group 5 prostate cancer of the right posterior lobe. A staging PSMA PET scan confirmed high local prostate avidity and no metastasis. The final histopathology demonstrated a pT3a stage cancer with clear surgical margins.\n\nRALP and discharge\nRALP was performed under general anesthetic in the 27-degrees trendelenburg position with a zero-degree telescope. A 24F rectal tube and 18F indwelling catheter (IDC) were inserted during the procedure. Hasson port was passed supraumbilically and insufflated to 10 mmHg with the remaining ports inserted under vision. The sigmoid colon was minimally released laterally to drop the bowel away from the working peritoneal space. There were no adhesions observed and the sigmoid was normal in appearance and attachment. The space of retzius was accessed and a routine prostatectomy was performed. Bladder neck was spared, bilateral nerve sparing was not performed, dorsal venous complex was cut and oversewn. Prior to vesicourethral anastomosis a negative rectal leak test with 60ml air was performed via a syringe, with insufflated air then removed and the rectal tube left open at the end till removal at case completion. The anastomosis was watertight with a negative 180 ml leak test. Total operative time was 160 minutes and estimated blood loss measured at 250 ml. The patient was discharged after two days and postoperative care included analgesia on demand, laxatives for three-days and enoxaparin venous thromboembolism (VTE) prophylaxis.\n\nED presentation\n19-days following RALP the patient presented to the emergency department (ED) with a three-day history of obstipation and reduced oral intake. He also presented with a two-day history of nausea, one episode of vomiting and back pain relieved by lying supine. He denied any abdominal pain, urinary symptoms, fevers or chills. He also denied any recent opioid use and was using paracetamol when required following RALP.\n\nOn examination his vitals were normal. His abdomen appeared very distended, however non-tender to light and deep palpation. There was no guarding or peritonism. Bowel sounds were hyperactive on auscultation. Digital rectal examination revealed an empty rectum with no blood or fecal matter.\n\nSigmoid volvulus diagnosis & management\nThe patient was admitted, and an abdominal & pelvis contrast-enhanced CT was performed revealing volvulus of the sigmoid colon. Flexible sigmoidoscopy confirmed a sigmoid volvulus 30 cm of insertion of the scope. There was no masses or blood, and the mucosa appeared normal and healthy. The patient underwent sigmoid detorsion and the colon was decompressed with insertion of a rectal tube. There were no procedural complications during the flexible sigmoidoscope. Postoperatively, he was commenced on regular metoclopramide, cetirizine, analgesia and osmotic laxatives. Postoperative stay was complicated by euglycemic ketoacidosis thus, seven days later the patient was discharged.\n\nTwo months after discharge, the patient presented again to ED with a similar three-day history of obstipation, progressive abdominal distension, reduced oral intake for two days, and dull generalized abdominal pain worse centrally. On examination his abdomen was very distended again, bowel loops were palpable and there was mild generalized tenderness with no guarding or rigidity.\n\nAbdominal & pelvis contrast-enhanced CT revealed another sigmoid volvulus, thus the decision was made to perform flexible sigmoidoscopy, detorsion and decompression of the volvulus and insertion of the rectal tube again. One month following his second episode of sigmoid volvulus, an elective anterior resection of the sigmoid colon was performed to prevent recurrence of symptoms following his urological procedure. No operative comment was made about abnormal clinical findings such as a narrow mesentery or large redundant sigmoid colon.", + "fulltext_subclaims": [ + "The patient was a 73-year-old male.", + "The patient was diagnosed with localized prostatic cancer.", + "The patient had long-standing metabolic syndrome.", + "The patient had two previous cerebrovascular accidents.", + "The patient's regular medications included aspirin.", + "The patient's regular medications included telmisartan.", + "The patient's regular medications included rosuvastatin.", + "The patient's regular medications included esomeprazole.", + "The patient's regular medications included empagliflozin.", + "The patient's regular medications included metformin.", + "The patient had no known allergies.", + "The patient was an ex-smoker.", + "The patient drank one bottle of wine a night.", + "The patient was referred to urology with an elevated PSA of 15.4 ng/ml.", + "The PSA was an increase from 8.13 ng/ml performed the year prior.", + "Multiparametric MRI demonstrated no lesion.", + "A transperineal prostate biopsy revealed Gleason 9 (G4+5) prostate cancer.", + "The Gleason score was grade group 5.", + "The cancer was located in the right posterior lobe.", + "A staging PSMA PET scan confirmed high local prostate avidity.", + "The staging PSMA PET scan showed no metastasis.", + "The final histopathology demonstrated a pT3a stage cancer.", + "The final histopathology showed clear surgical margins.", + "RALP was performed under general anesthetic.", + "RALP was performed in the 27-degrees trendelenburg position.", + "A 24F rectal tube was inserted during the procedure.", + "A 18F indwelling catheter was inserted during the procedure.", + "The Hasson port was passed supraumbilically.", + "The sigmoid colon was minimally released laterally.", + "The sigmoid colon was normal in appearance and attachment.", + "The space of retzius was accessed.", + "A routine prostatectomy was performed.", + "The bladder neck was spared.", + "Bilateral nerve sparing was not performed.", + "The dorsal venous complex was cut and oversewn.", + "A negative rectal leak test with 60ml air was performed.", + "The anastomosis was watertight.", + "A negative 180 ml leak test was performed.", + "The total operative time was 160 minutes.", + "The estimated blood loss measured at 250 ml.", + "The patient was discharged after two days.", + "Postoperative care included analgesia on demand.", + "Postoperative care included laxatives for three-days.", + "Postoperative care included enoxaparin venous thromboembolism prophylaxis.", + "19-days following RALP, the patient presented to the emergency department.", + "The patient had a three-day history of obstipation.", + "The patient had a two-day history of nausea.", + "The patient had one episode of vomiting.", + "The patient had back pain relieved by lying supine.", + "The patient denied any abdominal pain.", + "The patient denied any fevers or chills.", + "The patient denied any recent opioid use.", + "The patient was using paracetamol when required.", + "On examination, the abdomen appeared very distended.", + "The abdomen was non-tender to light and deep palpation.", + "There was no guarding or peritonism.", + "Bowel sounds were hyperactive.", + "Digital rectal examination revealed an empty rectum.", + "An abdominal & pelvis contrast-enhanced CT revealed volvulus of the sigmoid colon.", + "Flexible sigmoidoscopy confirmed a sigmoid volvulus.", + "The sigmoid volvulus was 30 cm of insertion of the scope.", + "There were no masses or blood.", + "The mucosa appeared normal and healthy.", + "The patient underwent sigmoid detorsion.", + "The colon was decompressed with insertion of a rectal tube.", + "There were no procedural complications.", + "Postoperatively, the patient was commenced on regular metoclopramide.", + "Postoperatively, the patient was commenced on cetirizine.", + "Postoperatively, the patient was commenced on osmotic laxatives.", + "The patient was discharged seven days later.", + "Two months after discharge, the patient presented again to ED.", + "The patient had a similar three-day history of obstipation.", + "The patient had progressive abdominal distension.", + "The patient had reduced oral intake for two days.", + "The patient had dull generalized abdominal pain.", + "On examination, the abdomen was very distended again.", + "Bowel loops were palpable.", + "There was mild generalized tenderness.", + "An abdominal & pelvis contrast-enhanced CT revealed another sigmoid volvulus.", + "The decision was made to perform flexible sigmoidoscopy.", + "The decision was made to perform detorsion and decompression of the volvulus.", + "The decision was made to insert a rectal tube again.", + "One month following his second episode of sigmoid volvulus, an elective anterior resection of the sigmoid colon was performed.", + "No operative comment was made about abnormal clinical findings." + ], + "summary": "A 73-year-old man underwent uncomplicated robotic-assisted laparoscopic prostatectomy (RALP). Nineteen days later, he developed constipation, obstipation, and distension. Imaging confirmed sigmoid volvulus, and he was subsequently managed with endoscopic detorsion. Recurrence occurred two months later, requiring colectomy. Sigmoid volvulus has not been reported after RALP.", + "summary_subclaims": [ + "The patient is a 73-year-old man.", + "He underwent uncomplicated robotic-assisted laparoscopic prostatectomy.", + "Nineteen days later, he developed constipation, obstipation, and distension.", + "Imaging confirmed sigmoid volvulus.", + "He was managed with endoscopic detorsion.", + "Recurrence occurred two months later.", + "Colectomy was required.", + "Sigmoid volvulus has not been reported after RALP." + ] + }, + { + "id": "multiclinsum_test_2299_en.txt", + "fulltext": "A 36-year-old male presented with a painless ulcer on the right forearm lasting for 2 mo.\nThe patient had been working in central Asia for several years. He returned to China after noticing a soybean-sized nodule that gradually increased in size to an ulcer over a period of 2 mo on the right forearm. He was initially diagnosed with a bacterial skin infection, but the treatment of debridement and levofloxacin (0.5 g/d orally for 7 d) was unsuccessful.\nThe patient was in good health and had no history of other diseases.\nThe patient had been working in central Asia for 3 years. Family history was unremarkable.\nA 5.8 cm × 4.0 cm ulcer on the right forearm with black crust in the center and raised borders was observed. After squeezing, a clear, thin liquid secretion appeared. Three hard, peanut-sized subcutaneous nodules could be palpated around the ulcer . No enlargement of lymph nodes was palpable in the right axilla or other areas.\nThe results from routine tests, such as blood, urine, stool routine, liver and kidney function and bacterial culture, were normal. Histopathological examination revealed diffuse mixed inflammatory cell infiltration within the superficial and deep layers of the dermis. Amastigote of Leishmania existed in the cytoplasm of the histocytes . Giemsa staining showed the amastigote more clearly . Leishman-Donovan bodies were seen on scrapings of the skin lesion , and no Leishman-Donovan bodies were seen on bone marrow smears. Serum immunoglobulin G antibody test of Leishmania donovani was negative.\nComputed tomography examination of the chest and abdomen showed no abnormalities.", + "fulltext_subclaims": [ + "The patient is a 36-year-old male.", + "He had a painless ulcer on the right forearm lasting for 2 mo.", + "The patient had been working in central Asia for several years.", + "He returned to China after noticing a soybean-sized nodule that gradually increased in size to an ulcer over a period of 2 mo on the right forearm.", + "He was initially diagnosed with a bacterial skin infection.", + "The treatment of debridement and levofloxacin (0.5 g/d orally for 7 d) was unsuccessful.", + "The patient had been working in central Asia for 3 years.", + "A 5.8 cm × 4.0 cm ulcer on the right forearm with black crust in the center and raised borders was observed.", + "After squeezing, a clear, thin liquid secretion appeared.", + "Three hard, peanut-sized subcutaneous nodules could be palpated around the ulcer.", + "No enlargement of lymph nodes was palpable in the right axilla or other areas.", + "The results from routine tests, such as blood, urine, stool routine, liver and kidney function and bacterial culture, were normal.", + "Histopathological examination revealed diffuse mixed inflammatory cell infiltration within the superficial and deep layers of the dermis.", + "Amastigote of Leishmania existed in the cytoplasm of the histocytes.", + "Giemsa staining showed the amastigote more clearly.", + "Leishman-Donovan bodies were seen on scrapings of the skin lesion.", + "No Leishman-Donovan bodies were seen on bone marrow smears.", + "Serum immunoglobulin G antibody test of Leishmania donovani was negative.", + "Computed tomography examination of the chest and abdomen showed no abnormalities." + ], + "summary": "We report a case of a 36-year-old male with cutaneous leishmaniasis. The patient had been misdiagnosed with a bacterial skin infection and was given a dressing change and oral levofloxacin, which proved ineffective. Histopathological examination revealed amastigote (Leishman-Donovan body) in the histocytes, and nucleic acid sequencing proved that the pathogen was Leishmania major. The patient was treated successfully by regional injection of sodium gluconate (600 mg) three times. The ulcer healed and did not recur at 1.5-year follow-up.", + "summary_subclaims": [ + "The patient was a 36-year-old male.", + "The patient had cutaneous leishmaniasis.", + "The patient had been misdiagnosed with a bacterial skin infection.", + "The patient was given a dressing change.", + "The patient was given oral levofloxacin.", + "The treatment with oral levofloxacin proved ineffective.", + "Histopathological examination revealed amastigote (Leishman-Donovan body) in the histocytes.", + "Nucleic acid sequencing proved that the pathogen was Leishmania major.", + "The patient was treated by regional injection of sodium gluconate.", + "The patient received 600 mg of sodium gluconate three times.", + "The ulcer healed.", + "The ulcer did not recur at 1.5-year follow-up." + ] + }, + { + "id": "multiclinsum_test_2177_en.txt", + "fulltext": "A 61-year-old white woman with an unremarkable medical history was referred for an evaluation of an asymptomatic retinal hemorrhage detected in her right eye. Her past ocular history was significant for a complete posterior vitreous detachment in the right eye. Her best-corrected visual acuity was 20/20 in each eye. Anterior segment examination and applanation tensions were unremarkable. Ophthalmoscopic examination of the right eye identified subretinal hemorrhage surrounding a pigment epithelial detachment (PED) located above the superotemporal vascular arcade . Spectral-domain optical coherence tomography (SD-OCT) demonstrated the presence of a PED accompanied by irregularities of the retinal pigment epithelium (RPE) profile . Optical coherence tomography (OCT) B-scan with angiographic flow overlay showed a peaked PED with intrinsic flow signal . Ophthalmoscopic examination of the left eye demonstrated a PED nasal to the optic nerve characterized by a dome-shaped elevation of the RPE with a shallow irregular portion on SD-OCT , whereas the angiographic flow overlay revealed intrinsic flow signal . Multiple, small, cuticular drusen appearing as small hypoautofluorescent dots on fundus autofluorescence (FAF) were seen in both eyes along the vascular arcades . Indocyanine green angiography (ICGA) showed focal areas of hyperfluorescence within the PEDs, indicative of AT1 .\nOCT angiography en face slab demonstrated aneurysmal dilatation arising from a type 1 neovascular network, particularly evident in the right eye with active lesions. As comparative imaging from the patient’s prior examination showed increased hemorrhage, treatment with anti-vascular endothelial growth factor (VEGF) therapy was initiated for the right eye at that time.", + "fulltext_subclaims": [ + "The patient is a 61-year-old white woman.", + "The patient had an asymptomatic retinal hemorrhage detected in her right eye.", + "The patient's past ocular history was significant for a complete posterior vitreous detachment in the right eye.", + "The patient's best-corrected visual acuity was 20/20 in each eye.", + "Ophthalmoscopic examination of the right eye identified subretinal hemorrhage surrounding a pigment epithelial detachment.", + "The pigment epithelial detachment was located above the superotemporal vascular arcade.", + "Spectral-domain optical coherence tomography demonstrated the presence of a pigment epithelial detachment.", + "Spectral-domain optical coherence tomography showed irregularities of the retinal pigment epithelium profile.", + "Optical coherence tomography B-scan with angiographic flow overlay showed a peaked pigment epithelial detachment with intrinsic flow signal.", + "Ophthalmoscopic examination of the left eye demonstrated a pigment epithelial detachment nasal to the optic nerve.", + "The pigment epithelial detachment in the left eye was characterized by a dome-shaped elevation of the retinal pigment epithelium.", + "The pigment epithelial detachment in the left eye had a shallow irregular portion on spectral-domain optical coherence tomography.", + "The angiographic flow overlay revealed intrinsic flow signal in the left eye pigment epithelial detachment.", + "Multiple, small, cuticular drusen were seen in both eyes along the vascular arcades.", + "The cuticular drusen appeared as small hypoautofluorescent dots on fundus autofluorescence.", + "Indocyanine green angiography showed focal areas of hyperfluorescence within the pigment epithelial detachments.", + "The focal areas of hyperfluorescence were indicative of AT1.", + "OCT angiography en face slab demonstrated aneurysmal dilatation arising from a type 1 neovascular network.", + "The aneurysmal dilatation was particularly evident in the right eye with active lesions.", + "Comparative imaging from the patient’s prior examination showed increased hemorrhage.", + "Treatment with anti-vascular endothelial growth factor therapy was initiated for the right eye." + ], + "summary": "A 61-year-old woman of European descent was referred for a new, asymptomatic retinal hemorrhage found on routine examination. Ophthalmoscopy revealed cuticular drusen in both eyes best appreciated on fundus autofluorescence, and a hemorrhagic retinal pigment epithelium detachment above the superior arcade in the right eye. In the fellow eye, a reddish appearing pigment epithelial detachment was noted nasal to the optic nerve. Indocyanine green angiography showed findings of AT1 in both eyes. Optical coherence tomography angiography showed intrinsic flow signal within the aneurysmal lesions.", + "summary_subclaims": [ + "The patient is a 61-year-old woman of European descent.", + "The patient was referred for a new, asymptomatic retinal hemorrhage found on routine examination.", + "Ophthalmoscopy revealed cuticular drusen in both eyes best appreciated on fundus autofluorescence.", + "A hemorrhagic retinal pigment epithelium detachment above the superior arcade in the right eye was noted.", + "In the fellow eye, a reddish appearing pigment epithelial detachment was noted nasal to the optic nerve.", + "Indocyanine green angiography showed findings of AT1 in both eyes.", + "Optical coherence tomography angiography showed intrinsic flow signal within the aneurysmal lesions." + ] + }, + { + "id": "multiclinsum_test_2254_en.txt", + "fulltext": "A previously healthy 56-year-old man developed gradual left- side hemiparesis, more accentuated in the lower limb (July 2016). A brain computerized tomography (CT)-scan and complementary magnetic resonance imaging (MRI) showed a solitary metastatic lesion (Met 1) in the right central sulcus (11.95 cc) with extensive perilesional edema [ and ]. The investigative tumor screening, including a CT- scan of the thorax and abdomen, revealed a suspect primary tumor in the left kidney as well as multiple, disseminated metastatic lesions in the lungs, liver, peri-aortic abdominal nodes, and left adrenal gland. A thrombotic mass positioned within the boundaries of the left renal vein was also reported. The subsequent biopsy revealed a clear cell renal cancer, Fuhrman Grade 2, as the primary. Due to the underlying extension of metastatic activity, nephrectomy was not indicated. Because of his relatively young age and previous healthy condition, the patient was accepted for upfront RRR- treatment of Met 1, structured on three separate fractions (GKRS 1–3) over a 7-day period [ and ]. This strategy aimed to sustain the patient’s performance status by avoiding further neurological deterioration while providing a window to start first-line targeted therapy (sunitinib). The rationale behind RRR can be found elsewhere in the literature.[-,]\nFollow-up MRI at 1, 3, and 6 months confirmed subsequent tumor volume reduction of Met 1 with ensuing significant improvement of the patient’s motor function . Notably, a discrete, nonsymptomatic adverse radiation effect (ARE) around Met 1 was reported at 3 months, however, this subsequently resolved at 6 and 10 months. Despite the positive evolution of Met 1, the corresponding follow-up MRI at 10 months demonstrated a new, large metastatic lesion (17.3 cc) with extensive perilesional edema within the confinements of the left frontotemporal region, threatening the area of Broca and the insular region (Met 2). A parasagittal micrometastasis in the posterior boundaries of the left temporal lobe was also reported (Met 3). Despite further thoracic disease progression on anti-PD1 treatment (nivolumab), the patient’s clinical condition remained stable (Karnofsky Performance Scale [KPS] 90, recursive partitioning analysis [RPA] Class II); it was, therefore, decided to treat Met 2 with RRR and Met 3 with SF-GKRS [ and ] before switching systemic treatment to axitinib.\nMet 2 decreased in volume by 15% between GKRS 1 and GKRS 3. Follow-up MRI at 14 months after RRR-treatment of Met 1 (=2 months after RRR-treatment of Met 2) showed further tumor volume reduction of Met 2 while Met 1 and Met 3 remained unchanged [-]. However, edema increment around Met 2 was also reported, suggesting an additional focal (yet asymptomatic) ARE. Due to further radiological evidence of extracranial disease progression (CT-scan thorax and abdomen, October 2017), low- tolerance to axitinib and the patient’s own choice, further systemic therapy was altogether disrupted 14 months post- RRR of Met 1. Last follow-up MRI (20 months after RRR of Met 1) showed almost complete ablation of all GKRS-treated lesions and a reduction in perifocal edema surrounding Met 2, without major corticosteroid intervention [- and -]. Despite remaining free from motor-sensory deficits, epileptic seizures (Engel score of 1) or cognitive impairment, the patient promptly deteriorated at this stage due to extracranial disease progression (KPS 50, RPA 3). The patient succumbed to his disease 21 months post-RRR-treatment of Met 1.", + "fulltext_subclaims": [ + "A previously healthy 56-year-old man developed gradual left-side hemiparesis, more accentuated in the lower limb in July 2016.", + "A brain CT-scan and MRI showed a solitary metastatic lesion in the right central sulcus with extensive perilesional edema.", + "The investigative tumor screening revealed a suspect primary tumor in the left kidney.", + "The biopsy revealed a clear cell renal cancer, Fuhrman Grade 2, as the primary.", + "Nephrectomy was not indicated due to the underlying extension of metastatic activity.", + "The patient was accepted for upfront RRR-treatment of Met 1, structured on three separate fractions over a 7-day period.", + "The strategy aimed to sustain the patient’s performance status by avoiding further neurological deterioration.", + "The strategy provided a window to start first-line targeted therapy (sunitinib).", + "Follow-up MRI at 1, 3, and 6 months confirmed subsequent tumor volume reduction of Met 1.", + "A discrete, nonsymptomatic adverse radiation effect around Met 1 was reported at 3 months.", + "The adverse radiation effect around Met 1 subsequently resolved at 6 and 10 months.", + "A new, large metastatic lesion with extensive perilesional edema within the left frontotemporal region was reported at 10 months.", + "A parasagittal micrometastasis in the posterior boundaries of the left temporal lobe was also reported.", + "The patient’s clinical condition remained stable despite further thoracic disease progression on anti-PD1 treatment (nivolumab).", + "It was decided to treat Met 2 with RRR and Met 3 with SF-GKRS before switching systemic treatment to axitinib.", + "Met 2 decreased in volume by 15% between GKRS 1 and GKRS 3.", + "Follow-up MRI at 14 months after RRR-treatment of Met 1 showed further tumor volume reduction of Met 2.", + "Edema increment around Met 2 was reported, suggesting an additional focal (yet asymptomatic) adverse radiation effect.", + "Further radiological evidence of extracranial disease progression was reported.", + "Further systemic therapy was altogether disrupted due to low tolerance to axitinib and the patient’s own choice.", + "Last follow-up MRI showed almost complete ablation of all GKRS-treated lesions.", + "The patient remained free from motor-sensory deficits, epileptic seizures, or cognitive impairment.", + "The patient succumbed to his disease 21 months post-RRR-treatment of Met 1." + ], + "summary": "A 56-year-old man presented with left-sided hemiparesis; the imaging showed a 13.1 cc brain metastasis in the right central sulcus (Met 1). Further investigation confirmed the histology to be a metastatic clear cell RCC. Met 1 was treated with upfront RRR. Follow-up magnetic resonance imaging (MRI) at 10 months showed further volume regression of Met 1; however, concurrently, a new 17.3 cc lesion was reported in the boundaries of the left frontotemporal region (Met 2) as well as a small metastasis (<1 cc) in the left temporal lobe (Met 3). Met 2 and Met 3 underwent RRR and SF-GKRS, respectively.", + "summary_subclaims": [ + "The patient is a 56-year-old man.", + "The patient presented with left-sided hemiparesis.", + "Imaging showed a 13.1 cc brain metastasis in the right central sulcus.", + "The histology was confirmed to be a metastatic clear cell RCC.", + "Met 1 was treated with upfront RRR.", + "Follow-up MRI at 10 months showed further volume regression of Met 1.", + "A new 17.3 cc lesion was reported in the boundaries of the left frontotemporal region.", + "A small metastasis (<1 cc) was reported in the left temporal lobe.", + "Met 2 underwent RRR.", + "Met 3 underwent SF-GKRS." + ] + }, + { + "id": "multiclinsum_test_2087_en.txt", + "fulltext": "A 40-year-old Caucasian man presented to our cardiologic outpatient department for regular cardiac evaluation. Dyspnoea or other cardiologic symptoms were negated by the patient. AA amyloidosis and associated end-stage chronic renal failure with need for constant dialysis due to highly active Ankylosing spondylitis was diagnosed 7 years ago and confirmed on kidney biopsy. At initial echocardiographic examination 4 years ago typical left ventricular wall thickening (19 mm) and ‘apical sparing’ with abnormal longitudinal function was stated, suspicion of CA was raised. Left ventricular ejection fraction (LVEF) was normal (60%). Yet, no aortic or mitral dysfunction was stated. No additional cardiac diagnostic modalities were done because of potential contrast agent side effects in absence of expected further therapeutic consequences. The patient continued his regular visits at the nephrology department. Due to arterial hypertension and LVH, regular antihypertensive and heart insufficiency medication was initiated (ramipril 5 mg b.i.d.; lercanidipine 10 mg b.i.d.). Anti-inflammatory therapy for ankylosing spondylitis consisted of 15 mg Prednisolone daily. Despite our recommendations no echocardiographic follow-up was performed in the following 4 years till the present visit.\nIn the present echo exam, the patient showed no change in LVH or LVEF. Surprisingly, while any cardiac symptoms were negated, the patient now showed severe aortic valve stenosis and mitral valve stenosis, the valves showing signs of massive calcification (see , , Video S1) (left ventricular end-diastolic volume: 51 mm, left ventricular end-systolic volume: 36 mm, no pericardial/pleural effusion, no left ventricular outflow tract obstruction, no systolic anterior movement, aortic valve mean pressure gradient: 30.56 mmHg, aortic valve Vmax: 3.8 m/s, aortic valve area: 1.1cm2, mitral valve mean pressure gradient: 13.92 mmHg, mitral valve area: 1.7cm2, no relevant aortic, mitral, or tricuspid valve regurgitation). N-terminal prohormone of brain natriuretic peptide was >70 000 ng/dL. Electrocardiogram showed regular sinus rhythm, without any conduction abnormalities. Clinical examination of the patient showed normal blood pressure (128/68 mmHg), normal heart rate (58 b.p.m.), rhythmic pulse and normal SpO2 (98%) by pulse oximetry. Auscultation revealed a 3/6 systolic, crescendo-decrescendo murmur, heard loudest at the 2nd right intercostal space. No peripheral oedema or increased jugular vein pulse was present. No hepatic or splenomegaly was present. Physical examination showed overheated and swollen knee joints. Due to suspicion of progressive systemic amyloidosis and ankylosing spondylitis a therapy with interleukin-6-receptor monoclonal human antibody (Tocilizumab) was initiated.\nFollowing discussion in the multidisciplinary cardiology meeting, the decision for surgical valve replacement of the aortic and mitral valve, due to fast progression, was made. A coronary angiography for preoperative evaluation showed no relevant coronary stenosis. Despite the high surgical risk in this patient, transcatheter aortic valve implantation was rejected by the Heart Team due to the young age and accompanying severe surgically treatable mitral valve disease in compliance with the current European Society of Cardiology (ESC) guidelines for the management of valvular heart disease.\nSurgical replacement of the aortic and mitral valve was conducted 8 weeks after severe aortic valve stenosis and mitral valve stenosis was diagnosed [23 mm Trifecta GT Aortic Valve (St. Jude Medical Abbott, St. Paul, MN, USA)/mitral valve prosthesis: 29 mm Hancock II (Medtronic, Dublin, Ireland)]. Macroscopic examination of the valves revealed significant calcification and were sent to our pathologic department for further examination. Both valve prosthetic devices showed normal function as well as a normal LVEF in initial post-operative transoesophageal echocardiography.\nHistopathological examination of the removed aortic and mitral valve showed severe calcification and the high presence of amyloid by Congo-red staining and immunohistological staining for AA-Amyloid (see ).\nPost-operatively the patient suffered from severe systemic inflammatory response syndrome (SIRS) with prolonged weaning, recurrent respiratory and abdominal septic shocks, cardiogenic shock due to cardiac arrhythmias and multiple further complications. Respiratory weaning was complicated by recurrent hospital-acquired pneumonia with proof of Citrobacter koseri and Stenotrophomonas maltophilia in bronchoalveolar lavage. Weaning remained without progress despite surgical tracheotomy and anti-infective treatment (Tazobactam/Piperacillin/Ciprofloxacin). Furthermore, the patient suffered from retractory Clostridium difficile enteritis, treated with vancomycine/fidaxomicine. A rectoscopy in suspicion of gastrointestinal bleeding (decrease in haemoglobin, peranal haemorrhage) revealed a defect of distal rectum with tissue necrosis. Aetiology of the defect remained unclear. An endosponge was inserted by laparoscopy and a protective ileostomy was placed, local peritonitis was seen intraoperatively. Two days after bowel surgery, the patient’s condition worsened with increasing demand of catecholamines in suspicion of abdominal septic shock. Additionally, the patient showed repeated ventricular arrhythmias with necessity of 10 min of reanimation and multiple defibrillations. The patient died 3 months after surgical valve replacement due to intractable multiorgan failure.", + "fulltext_subclaims": [ + "The patient is a 40-year-old Caucasian man.", + "The patient presented to the cardiologic outpatient department for regular cardiac evaluation.", + "The patient denied dyspnoea or other cardiologic symptoms.", + "AA amyloidosis and associated end-stage chronic renal failure with need for constant dialysis due to highly active Ankylosing spondylitis was diagnosed 7 years ago.", + "The diagnosis of AA amyloidosis was confirmed on kidney biopsy.", + "At initial echocardiographic examination 4 years ago, typical left ventricular wall thickening (19 mm) and ‘apical sparing’ with abnormal longitudinal function was stated.", + "A suspicion of CA was raised at the initial echocardiographic examination.", + "The left ventricular ejection fraction was normal (60%) at the initial echocardiographic examination.", + "No aortic or mitral dysfunction was stated at the initial echocardiographic examination.", + "No additional cardiac diagnostic modalities were done because of potential contrast agent side effects.", + "The patient continued his regular visits at the nephrology department.", + "Regular antihypertensive and heart insufficiency medication was initiated.", + "The anti-inflammatory therapy for ankylosing spondylitis consisted of 15 mg Prednisolone daily.", + "No echocardiographic follow-up was performed in the following 4 years till the present visit.", + "In the present echo exam, the patient showed no change in LVH or LVEF.", + "The patient now showed severe aortic valve stenosis and mitral valve stenosis.", + "The valves showed signs of massive calcification.", + "N-terminal prohormone of brain natriuretic peptide was >70 000 ng/dL.", + "Electrocardiogram showed regular sinus rhythm, without any conduction abnormalities.", + "Clinical examination showed normal blood pressure (128/68 mmHg).", + "Clinical examination showed normal heart rate (58 b.p.m.).", + "Auscultation revealed a 3/6 systolic, crescendo-decrescendo murmur, heard loudest at the 2nd right intercostal space.", + "A therapy with interleukin-6-receptor monoclonal human antibody (Tocilizumab) was initiated.", + "The decision for surgical valve replacement of the aortic and mitral valve was made.", + "A coronary angiography showed no relevant coronary stenosis.", + "Transcatheter aortic valve implantation was rejected by the Heart Team.", + "Surgical replacement of the aortic and mitral valve was conducted 8 weeks after severe aortic valve stenosis and mitral valve stenosis was diagnosed.", + "Macroscopic examination of the valves revealed significant calcification.", + "Histopathological examination of the removed aortic and mitral valve showed severe calcification.", + "The high presence of amyloid was found by Congo-red staining.", + "The high presence of amyloid was found by immunohistological staining for AA-Amyloid.", + "Post-operatively, the patient suffered from severe systemic inflammatory response syndrome.", + "The patient suffered from prolonged weaning.", + "The patient suffered from recurrent respiratory and abdominal septic shocks.", + "The patient suffered from cardiogenic shock due to cardiac arrhythmias.", + "The patient suffered from multiple further complications.", + "Respiratory weaning was complicated by recurrent hospital-acquired pneumonia.", + "Citrobacter koseri and Stenotrophomonas maltophilia were found in bronchoalveolar lavage.", + "Weaning remained without progress despite surgical tracheotomy and anti-infective treatment.", + "The patient suffered from retractive Clostridium difficile enteritis.", + "The patient was treated with vancomycine/fidaxomicine.", + "A rectoscopy in suspicion of gastrointestinal bleeding revealed a defect of distal rectum with tissue necrosis.", + "An endosponge was inserted by laparoscopy.", + "A protective ileostomy was placed.", + "Local peritonitis was seen intraoperatively.", + "The patient’s condition worsened with increasing demand of catecholamines in suspicion of abdominal septic shock.", + "The patient showed repeated ventricular arrhythmias with necessity of 10 min of reanimation and multiple defibrillations.", + "The patient died 3 months after surgical valve replacement due to intractable multiorgan failure." + ], + "summary": "A 40-year-old Caucasian man with known AA amyloidosis, highly active Ankylosing Spondylitis and need for chronic dialysis due to end-stage chronic renal failure presented for echocardiographic routine exam without reporting any cardiac symptoms. At the last visit 4 years ago, a normal heart valve function was noted and no echocardiographic follow-up was performed in the following. Now, rapid progression with severe aortic valve and mitral valve stenosis was stated and the patient underwent combined aortic and mitral surgical valve replacement following discussion in the multidisciplinary cardiology meeting. Macroscopic examination of the valves revealed significant calcification and histological examination showed the high presence of amyloid by Congo-red staining and immunohistological staining for AA-Amyloid. Both valve prosthetic devices showed normal function as well as a normal left ventricular ejection fraction in initial post-operative transoesophageal echocardiography. After prolonged and complicated post-operative course in the intensive care unit the patient died 3 months after surgery due to intractable multiorgan failure in combined severe abdominal septic and cardiogenic shock.", + "summary_subclaims": [ + "The patient is a 40-year-old Caucasian man.", + "The patient has known AA amyloidosis.", + "The patient has highly active Ankylosing Spondylitis.", + "The patient requires chronic dialysis due to end-stage chronic renal failure.", + "The patient presented for an echocardiographic routine exam.", + "The patient did not report any cardiac symptoms.", + "At the last visit 4 years ago, a normal heart valve function was noted.", + "No echocardiographic follow-up was performed in the following.", + "Rapid progression with severe aortic valve and mitral valve stenosis was stated.", + "The patient underwent combined aortic and mitral surgical valve replacement.", + "The decision for surgery followed discussion in the multidisciplinary cardiology meeting.", + "Macroscopic examination of the valves revealed significant calcification.", + "Histological examination showed the high presence of amyloid by Congo-red staining.", + "Histological examination showed immunohistological staining for AA-Amyloid.", + "Both valve prosthetic devices showed normal function in initial post-operative transoesophageal echocardiography.", + "A normal left ventricular ejection fraction was noted in initial post-operative transoesophageal echocardiography.", + "The patient had a prolonged and complicated post-operative course in the intensive care unit.", + "The patient died 3 months after surgery.", + "The patient died due to intractable multiorgan failure.", + "The patient died in combined severe abdominal septic and cardiogenic shock." + ] + }, + { + "id": "multiclinsum_test_534_en.txt", + "fulltext": "A 54-year-old male with dextrocardia true situs inversus, referred to our hospital due to traumatic syncope. He had history of coronary artery bypass grafting 4 months ago, and inferior wall myocardial infarction 3 months ago, as a result, he was not a candidate for any revascularization.\nHe had two attacks of syncope due to sustained monomorphic and polymorphic ventricular tachycardias and left ventricular ejection fraction of 35% by an echocardiogram done three weeks ago. Since he was not a candidate for further revascularization, we decided to implant a dual-chamber implantable cardioverter-defibrillator (ICD) . Before procedure, bilateral axillary venography, fluoroscopy, multislice computerized tomography angiography (MSCTA) were done which revealed dextrocardia with normal segmental cardiac anatomy of chambers and vascular bed. Venous access was gained via the left subclavian vein. Through a left-sided superior vena cava, two active leads were implanted in right ventricular apex (3830-59, Medtronic, Minneapolis, USA) and right atrial (5568 Medtronic, Minneapolis, MN, USA) appendage. shows the final position of the leads. The thresholds and senses were located appropriately. The leads are connected to a double-chamber ICD. Three months later, cardiovascular assessment of the patient was acceptable.", + "fulltext_subclaims": [ + "The patient is a 54-year-old male.", + "He has dextrocardia true situs inversus.", + "He was referred to the hospital due to traumatic syncope.", + "He had coronary artery bypass grafting 4 months ago.", + "He had an inferior wall myocardial infarction 3 months ago.", + "He was not a candidate for any revascularization.", + "He had two attacks of syncope.", + "The syncope was due to sustained monomorphic and polymorphic ventricular tachycardias.", + "His left ventricular ejection fraction was 35% by an echocardiogram done three weeks ago.", + "We decided to implant a dual-chamber implantable cardioverter-defibrillator.", + "Bilateral axillary venography, fluoroscopy, and multislice computerized tomography angiography were done.", + "The imaging revealed dextrocardia with normal segmental cardiac anatomy of chambers and vascular bed.", + "Venous access was gained via the left subclavian vein.", + "Two active leads were implanted in the right ventricular apex and right atrial appendage.", + "The leads were connected to a dual-chamber ICD.", + "Three months later, cardiovascular assessment of the patient was acceptable." + ], + "summary": "A 54-year-old male with dextrocardia situs inversus and ischemic left ventricular dysfunction developed ventricular tachycardia and fibrillation. Therefore, left- sided approach, dual chamber implantable cardioverter-defibrillator (ICD) was applied using a conventional method and standard equipment after complete evaluation of cardiac anatomy and vascular assessment.", + "summary_subclaims": [ + "The patient is a 54-year-old male.", + "The patient has dextrocardia situs inversus.", + "The patient has ischemic left ventricular dysfunction.", + "The patient developed ventricular tachycardia.", + "The patient developed fibrillation.", + "A left-sided approach was used.", + "A dual chamber implantable cardioverter-defibrillator was applied.", + "The ICD was applied using a conventional method.", + "Standard equipment was used.", + "A complete evaluation of cardiac anatomy was performed.", + "A vascular assessment was performed." + ] + }, + { + "id": "multiclinsum_test_212_en.txt", + "fulltext": "An 80-year-old woman noticed bloody discharge from her left nipple and palpated a lump in her left breast, and was referred to our hospital. Her mother had a history of breast cancer. Physical examination revealed a hard and immovable mass without skin adhesion in the upper lateral quadrant of the left breast. Cytologically, no malignant cells were found in the bloody discharge from the nipple. Laboratory data on admission were within normal limits. There was no elevation in serum levels of any tumor marker including CEA, CA15-3, NCC-ST-439, ICT, and CA19-9. Mammogram showed a focal asymmetry in the left CC-O and left MLO-M area . Ultrasonography revealed a hypoechoic mass measuring 19 × 17 × 11 mm with an irregular margin, acoustic enhancement, and interruption of the posterior border of the mammary gland in the upper lateral quadrant of the left breast. It was connected to the surrounding mammary ducts . The mammogram and ultrasonography were classified into the Breast Imaging Reporting and Data System (BI-RADS) 5th edition category 3 and 4, respectively. Contrast-enhanced magnetic resonance imaging (MRI) confirmed a mass with early enhancement. The mass had a relatively high intensity, and a peritumoral low-intensity capsule-like signal was noted on T2-weighted images . MRI also showed early arterial enhancement, gradual washout, and two lengths of linear enhancement between the mass and nipple . Core needle biopsy of the lesion demonstrated a solid, proliferating, and invasive tumor with adipose tissue involvement. These findings suggested invasive ductal carcinoma. The tumor was negative for estrogen receptor (ER) , progesterone receptor (PgR) , and HER2/neu . Positron emission tomography-computed tomography (PET-CT) revealed the breast tumor with a maximum standardized uptake value of 4.4 and also showed a 55-mm mass in the cervix uteri . Biopsy from the latter finally confirmed a diagnosis of cervical carcinoma. After radiotherapy for the cervical carcinoma, the patient underwent partial mastectomy and sentinel lymph node biopsy. She was not treated with neoadjuvant chemotherapy for her triple-negative breast carcinoma due to her great age and advanced cervical carcinoma.\nMacroscopically, the breast mass measured 35 mm in its greatest diameter and had no connection to the overlying skin or nipple . Histologically, the tumor revealed solid growth of small, round uniform cells with clear cytoplasm. In part, aggregates of large tumor cells with clear and vacuolated cytoplasm, indicative of sebaceous differentiation, were seen . The intraductal spread of the tumor was observed with bleeding in dilated ducts. A part of tumor nodule was surrounded by the fibrous tissue. No metastatic deposits were identified in the axillary lymph nodes. On frozen sections, most part of the tumor cells contained abundant Sudan Black B-positive lipid droplets in the cytoplasm . Immunohistochemically, 90% of the cells were positive for adipophilin . The cells were negative for ER, PgR, Her2/neu, and androgen receptor (AR); positive for cytokeratin 7 and Ber-EP4; and partially positive for epithelial membrane antigen (EMA). In addition, the tumor cells were negative for the neuroendocrine markers such as synaptophysin and chromogranin A. Therefore, the present case was diagnosed with sebaceous carcinoma of the breast. She had no complications of surgery and was discharged from the hospital on post-operative day 7.\nSixteen months after her breast surgery, the patient was admitted to the palliative care unit of another hospital due to her metastatic cervical carcinoma. There have been no signs of recurrence of breast malignancy.\nSebaceous carcinoma of the breast is a distinct variant of invasive ductal carcinoma, characterized by a lobular or nested growth pattern of tumor cells variably admixed with cells displaying sebaceous differentiation . According to the World Health Organization histological classification of tumors of the breast, the definition of the sebaceous carcinoma of the breast is that a primary breast carcinoma of the skin adnexal type with sebaceous differentiation at least 50% of cells and there should be no evidence of derivation from cutaneous adnexal sebaceous glands . The present case fulfilled the necessary condition.\nPathological diagnosis of sebaceous carcinoma of the breast is considered to be difficult when sebaceous differentiation is morphologically obscure. In such cases, it is necessary to show intracytoplasmic lipid by Oil Red O or Sudan Black B stain, or to demonstrate expression of adipophilin by immunohistochemistry. However, lipids are extracted during the organic phase of tissue processing and lipid staining cannot be performed in formalin-fixed paraffin-embedded material. Accordingly, lipid staining can vividly demonstrate intracytoplasmic lipid only when fresh frozen material is available . In the present case, intracytoplasmic lipids were identified through Sudan Black B and the tumor cells were immunohistochemically positive for adipophilin.\nSebaceous carcinoma should be differentiated from other rare types of breast carcinoma composed of vacuolated or clear cells, such as glycogen-rich carcinoma and lipid-rich carcinoma. Glycogen-rich carcinoma can be differentiated easily from sebaceous carcinoma by lack of lipids in the cytoplasm of neoplastic cell. Moreover, neoplastic cells of glycogen-rich carcinoma have a water-clear cytoplasm at light microscopy level, whereas sebaceous carcinoma is composed of vacuolated or foamy cells [, ]. Regarding lipid-rich carcinoma, at least 90% of tumor cells have abundant clear or vacuolated lipid-rich cytoplasm . Sebaceous carcinoma shows a compact lobulated solid growth pattern and finely vacuolated cells. In contrast, lipid-rich carcinoma infiltrates like conventional ductal carcinoma and the vacuolization is much less conspicuous.\nThere is no specific imaging finding that are useful in diagnosis of sebaceous carcinoma of the breast. In MRI of the present case, linear enhancement between mass and nipple and capsule-like signal were observed. The linear enhancement indicates intraductal spread of the tumor. It was identified pathologically with bleeding in dilated ducts that caused bloody discharge from her nipple. The capsule-like signal was pathologically consistent with the fibrous tissue surrounding the tumor nodule. However, they are not specific for sebaceous carcinoma.\nThe number of previously reported cases of sebaceous carcinoma of the breast is limited, and their clinical and pathological features are available in 12 cases [–]. According to the reported cases including ours, 12 patients were women with ages ranging from 25 to 80 years. ER, PgR, and HER2/neu showed positivity in 7 of 12, 8 of 12, and 3 of 9 cases, respectively. Although some hormones or the HER2/neu oncogene may have some role in the development of sebaceous carcinoma, the details are unknown.\nIt has been reported that sebaceous carcinoma of the breast might be high-grade malignant neoplasm because three of four patients had axillary lymph node metastases and two patients experienced an aggressive clinical course with distant metastases . On the other hand, seven eighths of the cases whose prognoses were available was alive with or without evidence of breast malignancy after operation. The clinical course is not generally known due to its rarity. Further study is warranted to elucidate the pathology and prognosis of the patients with sebaceous carcinoma of the breast.", + "fulltext_subclaims": [ + "An 80-year-old woman noticed bloody discharge from her left nipple.", + "She palpated a lump in her left breast.", + "She was referred to our hospital.", + "Her mother had a history of breast cancer.", + "Physical examination revealed a hard and immovable mass without skin adhesion in the upper lateral quadrant of the left breast.", + "Cytologically, no malignant cells were found in the bloody discharge from the nipple.", + "Laboratory data on admission were within normal limits.", + "There was no elevation in serum levels of any tumor marker including CEA, CA15-3, NCC-ST-439, ICT, and CA19-9.", + "Mammogram showed a focal asymmetry in the left CC-O and left MLO-M area.", + "Ultrasonography revealed a hypoechoic mass measuring 19 × 17 × 11 mm with an irregular margin, acoustic enhancement, and interruption of the posterior border of the mammary gland in the upper lateral quadrant of the left breast.", + "It was connected to the surrounding mammary ducts.", + "The mammogram and ultrasonography were classified into the BI-RADS 5th edition category 3 and 4, respectively.", + "Contrast-enhanced MRI confirmed a mass with early enhancement.", + "The mass had a relatively high intensity, and a peritumoral low-intensity capsule-like signal was noted on T2-weighted images.", + "MRI also showed early arterial enhancement, gradual washout, and two lengths of linear enhancement between the mass and nipple.", + "Core needle biopsy of the lesion demonstrated a solid, proliferating, and invasive tumor with adipose tissue involvement.", + "These findings suggested invasive ductal carcinoma.", + "The tumor was negative for estrogen receptor (ER), progesterone receptor (PgR), and HER2/neu.", + "PET-CT revealed the breast tumor with a maximum standardized uptake value of 4.4.", + "PET-CT also showed a 55-mm mass in the cervix uteri.", + "Biopsy from the latter finally confirmed a diagnosis of cervical carcinoma.", + "After radiotherapy for the cervical carcinoma, the patient underwent partial mastectomy and sentinel lymph node biopsy.", + "She was not treated with neoadjuvant chemotherapy for her triple-negative breast carcinoma due to her great age and advanced cervical carcinoma.", + "Macroscopically, the breast mass measured 35 mm in its greatest diameter and had no connection to the overlying skin or nipple.", + "Histologically, the tumor revealed solid growth of small, round uniform cells with clear cytoplasm.", + "In part, aggregates of large tumor cells with clear and vacuolated cytoplasm, indicative of sebaceous differentiation, were seen.", + "The intraductal spread of the tumor was observed with bleeding in dilated ducts.", + "A part of tumor nodule was surrounded by the fibrous tissue.", + "No metastatic deposits were identified in the axillary lymph nodes.", + "On frozen sections, most part of the tumor cells contained abundant Sudan Black B-positive lipid droplets in the cytoplasm.", + "Immunohistochemically, 90% of the cells were positive for adipophilin.", + "The cells were negative for ER, PgR, Her2/neu, and androgen receptor (AR); positive for cytokeratin 7 and Ber-EP4; and partially positive for epithelial membrane antigen (EMA).", + "The tumor cells were negative for the neuroendocrine markers such as synaptophysin and chromogranin A.", + "The present case was diagnosed with sebaceous carcinoma of the breast.", + "She had no complications of surgery and was discharged from the hospital on post-operative day 7.", + "Sixteen months after her breast surgery, the patient was admitted to the palliative care unit of another hospital due to her metastatic cervical carcinoma.", + "There have been no signs of recurrence of breast malignancy.", + "Sebaceous carcinoma of the breast is a distinct variant of invasive ductal carcinoma.", + "According to the World Health Organization histological classification of tumors of the breast, the definition of the sebaceous carcinoma of the breast is that a primary breast carcinoma of the skin adnexal type with sebaceous differentiation at least 50% of cells and there should be no evidence of derivation from cutaneous adnexal sebaceous glands.", + "The present case fulfilled the necessary condition.", + "Pathological diagnosis of sebaceous carcinoma of the breast is considered to be difficult when sebaceous differentiation is morphologically obscure.", + "In such cases, it is necessary to show intracytoplasmic lipid by Oil Red O or Sudan Black B stain, or to demonstrate expression of adipophilin by immunohistochemistry.", + "Lipids are extracted during the organic phase of tissue processing and lipid staining cannot be performed in formalin-fixed paraffin-embedded material.", + "Accordingly, lipid staining can vividly demonstrate intracytoplasmic lipid only when fresh frozen material is available.", + "In the present case, intracytoplasmic lipids were identified through Sudan Black B and the tumor cells were immunohistochemically positive for adipophilin.", + "Sebaceous carcinoma should be differentiated from other rare types of breast carcinoma composed of vacuolated or clear cells, such as glycogen-rich carcinoma and lipid-rich carcinoma.", + "Glycogen-rich carcinoma can be differentiated easily from sebaceous carcinoma by lack of lipids in the cytoplasm of neoplastic cell.", + "Neoplastic cells of glycogen-rich carcinoma have a water-clear cytoplasm at light microscopy level, whereas sebaceous carcinoma is composed of vacuolated or foamy cells.", + "Regarding lipid-rich carcinoma, at least 90% of tumor cells have abundant clear or vacuolated lipid-rich cytoplasm.", + "Sebaceous carcinoma shows a compact lobulated solid growth pattern and finely vacuolated cells.", + "In contrast, lipid-rich carcinoma infiltrates like conventional ductal carcinoma and the vacuolization is much less conspicuous.", + "There is no specific imaging finding that are useful in diagnosis of sebaceous carcinoma of the breast.", + "In MRI of the present case, linear enhancement between mass and nipple and capsule-like signal were observed.", + "The linear enhancement indicates intraductal spread of the tumor.", + "It was identified pathologically with bleeding in dilated ducts that caused bloody discharge from her nipple.", + "The capsule-like signal was pathologically consistent with the fibrous tissue surrounding the tumor nodule.", + "However, they are not specific for sebaceous carcinoma.", + "The number of previously reported cases of sebaceous carcinoma of the breast is limited, and their clinical and pathological features are available in 12 cases.", + "According to the reported cases including ours, 12 patients were women with ages ranging from 25 to 80 years.", + "ER, PgR, and HER2/neu showed positivity in 7 of 12, 8 of 12, and 3 of 9 cases, respectively.", + "Although some hormones or the HER2/neu oncogene may have some role in the development of sebaceous carcinoma, the details are unknown.", + "It has been reported that sebaceous carcinoma of the breast might be high-grade malignant neoplasm because three of four patients had axillary lymph node metastases and two patients experienced an aggressive clinical course with distant metastases.", + "On the other hand, seven eighths of the cases whose prognoses were available was alive with or without evidence of breast malignancy after operation.", + "The clinical course is not generally known due to its rarity.", + "Further study is warranted to elucidate the pathology and prognosis of the patients with sebaceous carcinoma of the breast." + ], + "summary": "An 80-year-old woman noted bloody discharge from her left nipple and palpated a lump in her left breast. Ultrasonography revealed a 19-mm mass in the left breast. Fine-needle aspiration suggested invasive ductal carcinoma. Partial mastectomy and sentinel lymph node biopsy were performed. On histological examination, the tumor revealed solid growth of small, round uniform cells with clear cytoplasm, partially intermingled with vacuolated cells indicative of sebaceous differentiation. The tumor cells contained abundant Sudan Black B-positive lipid droplets in the cytoplasm, and they were immunohistochemically positive for adipophilin. They were negative for estrogen receptor, progesterone receptor, and androgen receptor; positive for cytokeratin 7 and Ber-EP4; and partially positive for epithelial membrane antigen. Based on these findings, the patient was diagnosed with sebaceous carcinoma of the breast.", + "summary_subclaims": [ + "An 80-year-old woman noted bloody discharge from her left nipple.", + "She palpated a lump in her left breast.", + "Ultrasonography revealed a 19-mm mass in the left breast.", + "Fine-needle aspiration suggested invasive ductal carcinoma.", + "Partial mastectomy and sentinel lymph node biopsy were performed.", + "The tumor revealed solid growth of small, round uniform cells with clear cytoplasm.", + "The tumor cells were partially intermingled with vacuolated cells indicative of sebaceous differentiation.", + "The tumor cells contained abundant Sudan Black B-positive lipid droplets in the cytoplasm.", + "The tumor cells were immunohistochemically positive for adipophilin.", + "The tumor cells were negative for estrogen receptor.", + "The tumor cells were negative for progesterone receptor.", + "The tumor cells were negative for androgen receptor.", + "The tumor cells were positive for cytokeratin 7.", + "The tumor cells were positive for Ber-EP4.", + "The tumor cells were partially positive for epithelial membrane antigen.", + "The patient was diagnosed with sebaceous carcinoma of the breast." + ] + }, + { + "id": "multiclinsum_test_1783_en.txt", + "fulltext": "A 72-year-old man presented with a mass in the right parotid area that had become rapidly enlarged for 2 months. His medical history included a subtotal gastrectomy for a gastric ulcer 20 years earlier and low anterior resection for moderately differentiated adenocarcinoma of the rectum (Stage T1N0) 1 year earlier. Preoperative computed tomography (CT) showed a relatively well-defined heterogeneous enhancing solid lesion with calcification in the superficial lobe of the right parotid gland, with no indications of metastasis to the regional lymph nodes .\nFine-needle aspiration specimen showed that the tumor contained many clusters of malignant epithelial cells and scattered atypical spindle cells on a necrotic background. Under suspicion of a malignant tumor, the patient underwent total parotidectomy. Gross examination of the specimen revealed a multifocal, ill-defined, grayish-white, and heterogeneous solid tumor, accompanied by calcification and measuring 3 × 2.5 cm. Microscopically, the tumor was composed of two malignant components, carcinoma and sarcoma , with multifocal invasion (> 1.5 mm) of the capsule and adjacent tissues on a background of pre-existing pleomorphic adenoma and the osteosarcoma component was diffusely positive for vimentin . Both components showed some degree of nuclear immunoreactivity for p53 .\nFollowing surgery, the patient received postoperative radiation therapy. Six months later, he complained of abdominal pain. Abdominal CT showed a distension of small bowel with luminal narrowing and localized high density material in the abdominal cavity . The lesion was regarded as mechanical obstruction with postoperative adhesion because the patient had undergone previous abdominal surgery for rectal adenocarcinoma. After conservative management for several days, he experienced severe abdominal pain and an increased heart rate, and an emergency laparotomy was performed. Multiple hard calcified masses were observed in the abdominal walls, omentum, and mesentery, and mass excision with small bowel resection was done. On gross examination, bulky, gritty, and hemorrhagic mass adhered to the mesentery was identified . Microscopically, the tumors were identified as osteogenic sarcomas, with histologic features identical to those of the osteosarcomatous component of the carcinosarcoma of the parotid gland . The tumor cells were positive for vimentin on immunohistochemical staining . Because of its rapid development over 6 months and no history of osteosarcoma at any sites, we concluded that the abdominal osteosarcoma was metastatic from the carcinosarcoma of the parotid gland. The patient was postoperatively admitted to the intensive care unit and died of acute respiratory distress syndrome (ARDS) caused by aspiration pneumonia.", + "fulltext_subclaims": [ + "The patient is a 72-year-old man.", + "He presented with a mass in the right parotid area.", + "The mass had become rapidly enlarged for 2 months.", + "His medical history included a subtotal gastrectomy for a gastric ulcer 20 years earlier.", + "He had a low anterior resection for moderately differentiated adenocarcinoma of the rectum 1 year earlier.", + "The rectal tumor was Stage T1N0.", + "Preoperative CT showed a relatively well-defined heterogeneous enhancing solid lesion with calcification in the superficial lobe of the right parotid gland.", + "The CT showed no indications of metastasis to the regional lymph nodes.", + "Fine-needle aspiration showed the tumor contained many clusters of malignant epithelial cells.", + "The fine-needle aspiration specimen showed scattered atypical spindle cells on a necrotic background.", + "The patient underwent total parotidectomy.", + "Gross examination revealed a multifocal, ill-defined, grayish-white, and heterogeneous solid tumor.", + "The tumor measured 3 × 2.5 cm.", + "Microscopically, the tumor was composed of two malignant components, carcinoma and sarcoma.", + "The tumor showed multifocal invasion (> 1.5 mm) of the capsule and adjacent tissues.", + "The tumor was on a background of pre-existing pleomorphic adenoma.", + "The osteosarcoma component was diffusely positive for vimentin.", + "Both components showed some degree of nuclear immunoreactivity for p53.", + "The patient received postoperative radiation therapy.", + "Six months later, he complained of abdominal pain.", + "Abdominal CT showed distension of small bowel with luminal narrowing.", + "The CT showed localized high density material in the abdominal cavity.", + "The lesion was regarded as mechanical obstruction with postoperative adhesion.", + "The patient had undergone previous abdominal surgery for rectal adenocarcinoma.", + "After conservative management, he experienced severe abdominal pain and an increased heart rate.", + "An emergency laparotomy was performed.", + "Multiple hard calcified masses were observed in the abdominal walls, omentum, and mesentery.", + "Mass excision with small bowel resection was done.", + "Gross examination identified a bulky, gritty, and hemorrhagic mass adhered to the mesentery.", + "Microscopically, the tumors were identified as osteogenic sarcomas.", + "The histologic features were identical to those of the osteosarcomatous component of the carcinosarcoma of the parotid gland.", + "The tumor cells were positive for vimentin on immunohistochemical staining.", + "The abdominal osteosarcoma was concluded to be metastatic from the carcinosarcoma of the parotid gland.", + "The patient was postoperatively admitted to the intensive care unit.", + "He died of acute respiratory distress syndrome (ARDS) caused by aspiration pneumonia." + ], + "summary": "This report describes a rare case of carcinosarcoma of the parotid gland with an osteosarcoma as sarcomatous component in a 72-year-old man who had a history of low anterior resection for rectal cancer. Six months after parotidectomy, he presented abdominal pain as a symptom of abdominal metastasis by the sarcomatous component. At that time, the possibility of abdominal metastasis was overlooked because of the history of abdominal surgery. After several days of conservative treatment, emergency laparotomy was done. However, he died of acute respiratory distress syndrome.", + "summary_subclaims": [ + "This report describes a rare case of carcinosarcoma of the parotid gland with an osteosarcoma as sarcomatous component.", + "The patient was a 72-year-old man.", + "He had a history of low anterior resection for rectal cancer.", + "Six months after parotidectomy, he presented abdominal pain as a symptom of abdominal metastasis by the sarcomatous component.", + "The possibility of abdominal metastasis was overlooked because of the history of abdominal surgery.", + "After several days of conservative treatment, emergency laparotomy was done.", + "He died of acute respiratory distress syndrome." + ] + }, + { + "id": "multiclinsum_test_1895_en.txt", + "fulltext": "A 50-year-old otherwise healthy lady presented with complains of mild headache and diplopia for 8 weeks duration. On examination, she had the right lateral rectus palsy with diminished right corneal reflex. Radiology showed lesion extending from the cerebellopontine angle to the middle cranial fossa straddling across the petrous apex with its erosion [-]. There were mild ventriculomegaly and early papilledema for which a ventriculoperitoneal shunt was placed. Her headache improved and diplopia disappeared, though the sixth nerve paresis was apparent on examination.\nThe patient was offered surgery. However, she opted for upfront GKRS with presumptive diagnosis of trigeminal schwannoma. As the lesion was close to the brainstem, total dose of 25 Gy was administered. The patient was regularly followed up and showed no symptoms for a decade. Sequential MRI showed no increase in size or change in character of lesion [-]. However, in the past 6 months, she presented with features of pseudobulbar palsy (severe ataxia, difficulty in swallowing, change in voice, and spasticity) and the radiology showed significant increase in size of the lesion with brainstem compression and heterogeneous contrast enhancement [-].\nShe was operated through the right temporal craniotomy and interdural approach (by senior author PS). The tumor was grayish, fleshy with mild vascularity with a plane from the fifth nerve fascicles. Through the expanded Meckel’s cave, the component from posterior fossa was excised. Histopathology confirmed chondrosarcoma Grade II . Tumor cells were positive for S-100 and vimentin . The patient improved clinically and doing well at 8-month follow-up.", + "fulltext_subclaims": [ + "The patient is a 50-year-old otherwise healthy lady.", + "She presented with complains of mild headache and diplopia for 8 weeks duration.", + "On examination, she had the right lateral rectus palsy.", + "Radiology showed lesion extending from the cerebellopontine angle to the middle cranial fossa straddling across the petrous apex.", + "There was erosion of the petrous apex.", + "There were mild ventriculomegaly and early papilledema.", + "A ventriculoperitoneal shunt was placed.", + "Her headache improved.", + "Her diplopia disappeared.", + "The sixth nerve paresis was apparent on examination.", + "The patient was offered surgery.", + "She opted for upfront GKRS.", + "The presumptive diagnosis was trigeminal schwannoma.", + "The lesion was close to the brainstem.", + "A total dose of 25 Gy was administered.", + "The patient was regularly followed up.", + "She showed no symptoms for a decade.", + "Sequential MRI showed no increase in size or change in character of lesion.", + "In the past 6 months, she presented with features of pseudobulbar palsy.", + "The radiology showed significant increase in size of the lesion.", + "The radiology showed brainstem compression.", + "The radiology showed heterogeneous contrast enhancement.", + "The patient was operated through the right temporal craniotomy and interdural approach.", + "The tumor was grayish, fleshy with mild vascularity.", + "There was a plane from the fifth nerve fascicles.", + "Through the expanded Meckel’s cave, the component from posterior fossa was excised.", + "Histopathology confirmed chondrosarcoma Grade II.", + "Tumor cells were positive for S-100.", + "Tumor cells were positive for vimentin.", + "The patient improved clinically.", + "The patient was doing well at 8-month follow-up." + ], + "summary": "We report a case of chondrosarcoma, mimicking a trigeminal schwannoma treated with upfront radio surgery. Relatively lower dose was administered in view of proximity to the brainstem. The patient was asymptomatic and the size of the lesion remained static for over a decade. This was misinterpreted as effectiveness of GKRS. The lesion grew after a decade necessitating surgery.", + "summary_subclaims": [ + "The case involved chondrosarcoma.", + "The chondrosarcoma mimicked a trigeminal schwannoma.", + "The tumor was treated with upfront radiosurgery.", + "A relatively lower dose was administered.", + "The lower dose was due to proximity to the brainstem.", + "The patient was asymptomatic.", + "The size of the lesion remained static for over a decade.", + "The static size was misinterpreted as effectiveness of GKRS.", + "The lesion grew after a decade.", + "The lesion growth necessitated surgery." + ] + }, + { + "id": "multiclinsum_test_3065_en.txt", + "fulltext": "A 92-year-old female was referred to the Department of Urology, Kanazawa Medical University Hospital due to left lumber back pain. She had a history of asthma and chronic heart failure. She had no fever on arrival at the hospital. Physical examination revealed left costal-vertebral angle (CVA) knocking pain.\n\n\nInvestigations\n\nAbdominal CT showed a left hydroureteronephrosis and obstruction of the left distal ureter with herniation into the sciatic foramen.\n\nShe underwent retrograde ureterography (RP), which showed definite tortuosity of the left ureter in the sciatic foramen.\n\n\nTreatment\n\nA guidewire was inserted into the left ureter and was linearized. A retro-grade placement of the 6Fr ureteral stent.\n\n\nOutcome and follow-up\n\nNo recurrence of the ureterosciatic hernia was observed after the ureteral stent was removed at 12 month follow-up.", + "fulltext_subclaims": [ + "A 92-year-old female was referred to the Department of Urology, Kanazawa Medical University Hospital due to left lumber back pain.", + "She had a history of asthma.", + "She had a history of chronic heart failure.", + "She had no fever on arrival at the hospital.", + "Physical examination revealed left costal-vertebral angle (CVA) knocking pain.", + "Abdominal CT showed a left hydroureteronephrosis.", + "Abdominal CT showed obstruction of the left distal ureter with herniation into the sciatic foramen.", + "She underwent retrograde ureterography (RP).", + "Retrograde ureterography showed definite tortuosity of the left ureter in the sciatic foramen.", + "A guidewire was inserted into the left ureter and was linearized.", + "A retro-grade placement of the 6Fr ureteral stent was performed.", + "No recurrence of the ureterosciatic hernia was observed after the ureteral stent was removed at 12 month follow-up." + ], + "summary": "A 92-year-old female with a history of asthma and chronic heart failure presented with left lumber back pain. Physical examination revealed knocking tenderness at the left costal-vertebral angle. Laboratory test results were within normal limits. Abdominal CT showed a left hydroureteronephrosis and an obstruction in the left distal ureter with herniation into the sciatic foramen. A ureteral stent was inserted into the left ureter and was removed after 2 months. She has not complained of pain or showed symptoms since the removal.", + "summary_subclaims": [ + "The patient is a 92-year-old female.", + "The patient has a history of asthma.", + "The patient has a history of chronic heart failure.", + "The patient presented with left lumber back pain.", + "Physical examination revealed knocking tenderness at the left costal-vertebral angle.", + "Laboratory test results were within normal limits.", + "Abdominal CT showed a left hydroureteronephrosis.", + "Abdominal CT showed an obstruction in the left distal ureter.", + "The obstruction herniated into the sciatic foramen.", + "A ureteral stent was inserted into the left ureter.", + "The ureteral stent was removed after 2 months.", + "She has not complained of pain since the removal.", + "She has not shown symptoms since the removal." + ] + }, + { + "id": "multiclinsum_test_544_en.txt", + "fulltext": "A 50-year-old Japanese woman presented to a hospital with left-sided abdominal distention. Abdominal ultrasonography revealed a cystic mass in the left-lower quadrant of the abdomen measuring approximately 10 cm in diameter. The patient had a history of iron deficiency anemia due to menorrhagia. She was referred to our hospital for surgical management. Upon admission, she complained of left-sided abdominal distention and denied abdominal pain and nausea. Physical examination revealed mild distention and a mildly tender mass in the left-lower quadrant of the abdomen. Laboratory examination findings on admission revealed elevated serum tumor marker levels: carcinoembryonic antigen (CEA) level of 21.4 ng/mL (normal range: 0–5.0) and carbohydrate antigen 19-9 (CA19-9) level of 804.0 U/mL (normal range: 0–37.0). Other laboratory results were normal except for a low hemoglobin level of 10.4 g/dL. Abdominal US revealed a tumor located in the left abdomen with a maximum diameter of about 9 cm. The cyst wall was about 4 mm thick and relatively uniform, with no septa or nodules visible within the cyst. Enhanced computed tomography (CT) and magnetic resonance imaging (MRI) of the abdomen revealed a 10.2 × 9.1 × 9.3-cm-sized unilocular cystic lesion with maximum 12-mm-sized nodules located on the left side of the abdomen . CT revealed three uniform contrast-enhanced nodules similar to the cyst wall. The boundary between the nodule and the wall was unclear for all three nodules; one of the nodules was seen as a gentle ridge. MRI revealed three nodules in the cyst, and the nodules and cyst wall showed low signal intensity on T1-weighted images and high signal intensity on T2-weighted images. The cystic mass was close to the left ureter, proximal jejunum, and descending colon, but separated from the left kidney and pancreas. The cyst wall was 3-mm thick. 18F-fluorodeoxyglucose (FDG)-PET/CT revealed mottled mild FDG uptake in the whole cyst wall and intense FDG uptake in the mural nodules with standardized uptake value (SUV)-max of 16.15, and no abnormal FDG uptake in other organs . There were no malignant tumors on endoscopic gastrointestinal examination, and no findings to suspect gynecological diseases such as ovarian tumors. Although we were not able to identify the exact origin of the cyst based on radiological findings alone, we suspected a primary malignant cystic tumor arising from the retroperitoneum.\nA midline laparotomy was performed after confirming the absence of disseminated lesions by laparoscopy and it revealed a cystic mass located in the mesentery of the descending colon . The cystic mass was rigidly attached to the descending colon, but not adhered to any other organs. The arterial supply of the tumor originated from the left colic artery; based on this, we diagnosed a mesenteric cystic tumor rather than a retroperitoneal cystic tumor. The cystic mass with the descending colon were completely removed without rupture.\nThe surgical specimen measured 9.2 × 9.2 × 6.5 cm . The cyst contained a serous, cloudy, ‘café-au-lait-like’ fluid . The pathological diagnosis of the specimen was adenocarcinoma. However, it was difficult to determine the histopathological subtypes (mucinous, serous, or seromucinous) due to the atypical histologic findings. The inner surface of the cyst wall was lined predominantly by a single layer to multiple layers of columnar epithelium and partially by simple cuboidal epithelium. The nodules consisted of atypical cells that showed nuclear atypia and abundant clear or eosinophilic cytoplasm composed of an irregular glandular or sheet-like structure with stromal infiltration , and the surface was covered with papillovillous component . The mesenteric tumor slightly invaded the subserosal layer of the descending colon, but not the mucosal layer. No ovarian stroma or teratomatous elements, including ectopic endometriosis, were observed. The atypical cells were immunohistochemically reactive for cytokeratin 7 (CK7), and p53, but negative for cytokeratin 20 (CK20), estrogen receptor (ER), progesterone receptor (PgR), Wilms’ tumor gene-1, napsin A, and calretinin. Therefore, the final diagnosis was primary cystadenocarcinoma arising from the mesentery of the descending colon; the atypical cells were immunohistochemically reactive for CEA and CA19-9 .\nThe postoperative course was uneventful, and the patient was discharged 11 days after the surgery. Adjuvant chemotherapy was initiated with S-1 (TS-1; tegafur, gimeracil, and oteracil potassium) at 100 mg/kg body weight per day for 8 courses (4 weeks of administration and 2 weeks of discontinuation). Approximately 1 year after the surgery, abdominal CT revealed no signs of disease recurrence, and serum CEA and CA19-9 levels had returned to normal.", + "fulltext_subclaims": [ + "The patient was a 50-year-old Japanese woman.", + "She presented with left-sided abdominal distention.", + "Abdominal ultrasonography revealed a cystic mass in the left-lower quadrant of the abdomen measuring approximately 10 cm in diameter.", + "The patient had a history of iron deficiency anemia due to menorrhagia.", + "She was referred to the hospital for surgical management.", + "Upon admission, she complained of left-sided abdominal distention.", + "She denied abdominal pain and nausea.", + "Physical examination revealed mild distention and a mildly tender mass in the left-lower quadrant of the abdomen.", + "Serum carcinoembryonic antigen (CEA) level was 21.4 ng/mL.", + "Serum carbohydrate antigen 19-9 (CA19-9) level was 804.0 U/mL.", + "Hemoglobin level was 10.4 g/dL.", + "Abdominal US revealed a tumor located in the left abdomen with a maximum diameter of about 9 cm.", + "The cyst wall was about 4 mm thick and relatively uniform, with no septa or nodules visible within the cyst.", + "Enhanced CT and MRI revealed a 10.2 × 9.1 × 9.3-cm-sized unilocular cystic lesion on the left side of the abdomen.", + "CT revealed three uniform contrast-enhanced nodules similar to the cyst wall.", + "MRI revealed three nodules in the cyst.", + "The cystic mass was close to the left ureter, proximal jejunum, and descending colon.", + "The cyst wall was 3-mm thick.", + "FDG-PET/CT revealed mottled mild FDG uptake in the whole cyst wall.", + "FDG-PET/CT revealed intense FDG uptake in the mural nodules with SUV-max of 16.15.", + "There were no malignant tumors on endoscopic gastrointestinal examination.", + "No findings to suspect gynecological diseases such as ovarian tumors were found.", + "We suspected a primary malignant cystic tumor arising from the retroperitoneum.", + "A midline laparotomy was performed after confirming the absence of disseminated lesions by laparoscopy.", + "The cystic mass was located in the mesentery of the descending colon.", + "The cystic mass was rigidly attached to the descending colon.", + "The arterial supply of the tumor originated from the left colic artery.", + "The cystic mass with the descending colon were completely removed without rupture.", + "The surgical specimen measured 9.2 × 9.2 × 6.5 cm.", + "The cyst contained a serous, cloudy, 'café-au-lait-like' fluid.", + "The pathological diagnosis of the specimen was adenocarcinoma.", + "It was difficult to determine the histopathological subtypes due to the atypical histologic findings.", + "The inner surface of the cyst wall was lined predominantly by a single layer to multiple layers of columnar epithelium.", + "The nodules consisted of atypical cells that showed nuclear atypia and abundant clear or eosinophilic cytoplasm.", + "The mesenteric tumor slightly invaded the subserosal layer of the descending colon.", + "No ovarian stroma or teratomatous elements were observed.", + "The atypical cells were immunohistochemically reactive for cytokeratin 7 (CK7), and p53.", + "The atypical cells were negative for cytokeratin 20 (CK20), estrogen receptor (ER), progesterone receptor (PgR), Wilms’ tumor gene-1, napsin A, and calretinin.", + "The final diagnosis was primary cystadenocarcinoma arising from the mesentery of the descending colon.", + "The atypical cells were immunohistochemically reactive for CEA and CA19-9.", + "The postoperative course was uneventful.", + "The patient was discharged 11 days after the surgery.", + "Adjuvant chemotherapy was initiated with S-1 at 100 mg/kg body weight per day for 8 courses.", + "Approximately 1 year after the surgery, abdominal CT revealed no signs of disease recurrence.", + "Serum CEA and CA19-9 levels had returned to normal." + ], + "summary": "A 50-year-old Japanese woman had a complaint of a left-sided abdominal distention. Enhanced computed tomography and magnetic resonance imaging revealed a unilocular cystic lesion measuring approximately 10 cm located in the left side of the abdomen. 18F-fluorodeoxyglucose (FDG)-positron emission tomography/computed tomography (PET/CT) revealed mottled mild FDG uptake in the cyst wall and intense FDG uptake in several mural nodules. The cystic mass with the descending colon was completely removed. Pathological examination of the specimens revealed various histologic patterns of adenocarcinoma, including mucin production in the mural nodules. We eventually diagnosed a primary cystadenocarcinoma arising from the mesentery of the descending colon.", + "summary_subclaims": [ + "The patient was a 50-year-old Japanese woman.", + "The patient had a complaint of a left-sided abdominal distention.", + "Enhanced computed tomography and magnetic resonance imaging revealed a unilocular cystic lesion measuring approximately 10 cm located in the left side of the abdomen.", + "18F-fluorodeoxyglucose (FDG)-positron emission tomography/computed tomography (PET/CT) revealed mottled mild FDG uptake in the cyst wall.", + "18F-fluorodeoxyglucose (FDG)-positron emission tomography/computed tomography (PET/CT) revealed intense FDG uptake in several mural nodules.", + "The cystic mass with the descending colon was completely removed.", + "Pathological examination of the specimens revealed various histologic patterns of adenocarcinoma.", + "Pathological examination of the specimens revealed mucin production in the mural nodules.", + "We eventually diagnosed a primary cystadenocarcinoma arising from the mesentery of the descending colon." + ] + }, + { + "id": "multiclinsum_test_1007_en.txt", + "fulltext": "A 51-year-old Japanese man developed gross hematuria. He visited a local hospital where he underwent abdominal computed tomography, which revealed many cysts with calcification inside the left kidney. He was then referred to our hospital for further examination. A blood test showed no abnormal findings. Urinary cytology yielded a pseudo-positive result (class 3). However, dynamic contrast-enhanced computed tomography revealed a mass, which showed enhancement in the early phase and appeared washed out in the late phase, in a cyst at the upper pole of the left kidney . Magnetic resonance imaging revealed a tumor with an abnormal signal on a diffusion-weighted image . Retrograde pyelography showed no wall irregularity at the left renal pelvis, and urinary cytology of samples from the left pelvis and urinary tract yielded negative results. He was diagnosed with left cystic renal cell carcinoma (cT1N0M0) and underwent retroperitoneal laparoscopic nephrectomy. The surgical specimen showed a cystic lesion filled with papillary formation . Microstones and brownish liquid retention were also observed inside the cystic lesion. Pathological examination revealed that the wall of the cystic lesion was covered with urothelial cells and high-grade urothelial carcinoma with renal parenchymal invasion. In immunohistochemical staining, GATA3, p63, and p40 were positive and PAX8 was negative. The definitive pathological diagnosis was urothelial carcinoma originating from the renal pyelocalyceal diverticulum, invasive urothelial carcinoma, high-grade (G3), and pT3. An additional residual ureterectomy and two courses of gemcitabine and cisplatin adjuvant chemotherapy were performed. Pathological examination showed no malignant findings of the residual ureter, and no recurrence was observed during the 12-month follow-up.", + "fulltext_subclaims": [ + "A 51-year-old Japanese man developed gross hematuria.", + "He visited a local hospital where he underwent abdominal computed tomography.", + "Abdominal computed tomography revealed many cysts with calcification inside the left kidney.", + "He was referred to our hospital for further examination.", + "A blood test showed no abnormal findings.", + "Urinary cytology yielded a pseudo-positive result (class 3).", + "Dynamic contrast-enhanced computed tomography revealed a mass.", + "The mass showed enhancement in the early phase.", + "The mass appeared washed out in the late phase.", + "The mass was in a cyst at the upper pole of the left kidney.", + "Magnetic resonance imaging revealed a tumor with an abnormal signal on a diffusion-weighted image.", + "Retrograde pyelography showed no wall irregularity at the left renal pelvis.", + "Urinary cytology of samples from the left pelvis and urinary tract yielded negative results.", + "He was diagnosed with left cystic renal cell carcinoma (cT1N0M0).", + "He underwent retroperitoneal laparoscopic nephrectomy.", + "The surgical specimen showed a cystic lesion filled with papillary formation.", + "Microstones and brownish liquid retention were observed inside the cystic lesion.", + "Pathological examination revealed that the wall of the cystic lesion was covered with urothelial cells.", + "Pathological examination revealed high-grade urothelial carcinoma with renal parenchymal invasion.", + "In immunohistochemical staining, GATA3 was positive.", + "In immunohistochemical staining, p63 was positive.", + "In immunohistochemical staining, p40 was positive.", + "In immunohistochemical staining, PAX8 was negative.", + "The definitive pathological diagnosis was urothelial carcinoma originating from the renal pyelocalyceal diverticulum.", + "The definitive pathological diagnosis was invasive urothelial carcinoma, high-grade (G3).", + "The definitive pathological diagnosis was pT3.", + "An additional residual ureterectomy was performed.", + "Two courses of gemcitabine and cisplatin adjuvant chemotherapy were performed.", + "Pathological examination showed no malignant findings of the residual ureter.", + "No recurrence was observed during the 12-month follow-up." + ], + "summary": "A 51-year-old Japanese man complained of gross hematuria. Computed tomography revealed a solid mass in one of the many cystic lesions in the left kidney. He was diagnosed with left cystic renal cell carcinoma and underwent retroperitoneal laparoscopic nephrectomy. Pathological examination revealed high-grade invasive urothelial carcinoma arising within the renal pyelocalyceal diverticulum. The definitive diagnosis was high-grade invasive urothelial carcinoma (pT3). In retrospect, the retrograde pyelography findings indicated the cyst and urinary tract connection. Residual ureterectomy and adjuvant chemotherapy were later performed. The patient has since been recurrence-free.", + "summary_subclaims": [ + "The patient is a 51-year-old Japanese man.", + "The patient complained of gross hematuria.", + "Computed tomography revealed a solid mass in one of the many cystic lesions in the left kidney.", + "He was diagnosed with left cystic renal cell carcinoma.", + "He underwent retroperitoneal laparoscopic nephrectomy.", + "Pathological examination revealed high-grade invasive urothelial carcinoma arising within the renal pyelocalyceal diverticulum.", + "The definitive diagnosis was high-grade invasive urothelial carcinoma (pT3).", + "In retrospect, the retrograde pyelography findings indicated the cyst and urinary tract connection.", + "Residual ureterectomy and adjuvant chemotherapy were later performed.", + "The patient has since been recurrence-free." + ] + }, + { + "id": "multiclinsum_test_1737_en.txt", + "fulltext": "An 18-year-old male patient presented with symptoms of pain and swelling localized on the medial aspect of his right ankle joint, specifically at the medial malleolus. The patient noted a recent history of a twisting injury of his right ankle 6-months before presentation at our specialty orthopedic clinic. The injury occurred while playing football. Initially, he was treated by his general practitioner, who assumed it to be a severe sprain injury and had placed him on a course of ice compress and anti-inflammatory medication followed by a below knee plaster cast for a period of 3 weeks. Following this treatment protocol, the patient was able to walk but reported on-going pain while walking once the plaster cast was removed. No radiographic imaging was done at the time and was therefore not available for review and comparison.\nOn further examination, swelling was observed over the distal aspect of the medial malleolus, along with tenderness over deltoid ligament of the right ankle. There was no bone related tenderness at the distal tibia. Ankle joint movement was also observed to be normal. We proceeded with a thorough radiograph examination including standard X-rays and 3-dimensional computed tomography (CT) scanning of the right ankle, which revealed the presence of a small bone fragment located anterior and distal to the medial malleolus (, ). This fragment was not free floating and rather appeared to be attached to the distal tibia. Furthermore, it was a uni-lateral presentation as the patient’s left ankle anatomy did not reveal the presence of a similar bone fragment and was rather normal in appearance . Based on our findings as well as the findings of previously published reports on this topic, a benefit of doubt was provided, and it was assumed to be a case of acute trauma, leading to a small fracture of the anterior aspect of the distal tibia.\nAt first consultation, the patient was explained of his diagnosis and offered a conservative treatment protocol that included a compression bandage and anti-inflammatory medication. Since this had minimal effect on his symptoms, he was placed in a plaster cast for period of 6 weeks thereafter. Following removal of the cast, the patient’s symptoms re-occurred, and at that point, he had been on a conservative treatment regimen for almost 10 months with no significant clinical benefit. Based on this, it was considered that this might be a case of differential diagnosis, with the possibility of it being the case of a symptomatic Os subtibiale. At that stage, a surgery appeared to be the best option to help this patient with his symptoms. It was noted that intraoperatively, this surgery may involve either fixation of the bone fragment if it was deemed to be a fracture, or removal of the same if it appeared to be an Os subtibiale. The patient was then offered a surgical treatment option to which he consented and agreed to proceed as necessary.\nOn admission to the operating theater, the patient was positioned supine and administered general anesthesia. An upper thigh tourniquet was used on the patient’s right leg in this case. To gain access to the distal tibia, a 4–5 cm anterior mid-line incision over right ankle joint was performed . The surrounding soft-tissue structures, superficial nerve, and vascular structures were carefully protected and retracted to gain exposure to the distal tibia, which revealed the presence of a smooth and oblong bone fragment attached to the anterior-distal aspect of the medial malleolus, as was observed in the X-ray and CT imaging . Based on its appearance, and the lack of bony fusion like characteristics with the adjacent distal tibia, this bone fragment was deemed to be an Os subtibiale. In addition, the margins of the distal tibia marked with a surgical marker, without considering the Os subtibiale, gave the appearance of a normal medial malleolus. It was also observed that it was pressing directly on the deltoid ligament, which explained the on-going pain that the patient experienced while walking. The deltoid ligament was released and the Os subtibiale was then surgically excised using a small 3 mm osteotome and a small bone rongeur. It was measured to be approximately 2 × 11 × cm3 in size . Following excision, the surrounding bone and soft-tissue structures were carefully examined to ensure that there were no other anatomical bone or soft tissues abnormalities that could be contributing to the patient’s symptoms. On confirmation, the surgical area was thoroughly irrigated with saline, and standard surgical procedures were used to close the incision in a layer by layer fashion. A standard surgical dressing was applied over the operated site, and the foot was placed in a heavy compressive bandage for the next 2 weeks. This was followed by ankle mobilization and stretching exercises as tolerated by the patient. At his latest follow-up of 18 months, the patient reported to be pain free and displayed normal range of motion at the ankle joint compared to his non-operated, contra-lateral left foot. He also consented to participating in this study.", + "fulltext_subclaims": [ + "The patient is an 18-year-old male.", + "The patient presented with pain and swelling localized on the medial aspect of his right ankle joint.", + "The patient had a twisting injury of his right ankle 6 months before presentation.", + "The injury occurred while playing football.", + "The general practitioner assumed it to be a severe sprain injury.", + "The general practitioner placed the patient on a course of ice compress and anti-inflammatory medication.", + "The general practitioner placed the patient in a below-knee plaster cast for a period of 3 weeks.", + "The patient was able to walk after the plaster cast was removed.", + "The patient reported ongoing pain while walking after the plaster cast was removed.", + "No radiographic imaging was done at the time of the initial injury.", + "Swelling was observed over the distal aspect of the medial malleolus.", + "Tenderness was observed over the deltoid ligament of the right ankle.", + "There was no bone-related tenderness at the distal tibia.", + "Ankle joint movement was observed to be normal.", + "Radiographic examination included standard X-rays and 3-dimensional computed tomography (CT) scanning of the right ankle.", + "A small bone fragment was located anterior and distal to the medial malleolus.", + "The fragment was not free floating and appeared to be attached to the distal tibia.", + "The fragment was a unilateral presentation.", + "The patient’s left ankle anatomy did not reveal the presence of a similar bone fragment.", + "The patient was offered a conservative treatment protocol that included a compression bandage and anti-inflammatory medication.", + "The conservative treatment had minimal effect on the patient’s symptoms.", + "The patient was placed in a plaster cast for a period of 6 weeks.", + "Following removal of the cast, the patient’s symptoms re-occurred.", + "The patient had been on a conservative treatment regimen for almost 10 months with no significant clinical benefit.", + "A surgery was considered to be the best option.", + "The surgery may involve either fixation of the bone fragment if it was deemed to be a fracture, or removal of the same if it appeared to be an Os subtibiale.", + "The patient consented to proceed with the surgical treatment.", + "The patient was positioned supine and administered general anesthesia.", + "An upper thigh tourniquet was used on the patient’s right leg.", + "A 4–5 cm anterior mid-line incision over the right ankle joint was performed.", + "The surrounding soft-tissue structures, superficial nerve, and vascular structures were carefully protected and retracted.", + "A smooth and oblong bone fragment was attached to the anterior-distal aspect of the medial malleolus.", + "The fragment was deemed to be an Os subtibiale.", + "The Os subtibiale was pressing directly on the deltoid ligament.", + "The deltoid ligament was released.", + "The Os subtibiale was surgically excised using a small 3 mm osteotome and a small bone rongeur.", + "The excised Os subtibiale was measured to be approximately 2 × 11 × cm3 in size.", + "The surgical area was thoroughly irrigated with saline.", + "The incision was closed in a layer by layer fashion.", + "A standard surgical dressing was applied over the operated site.", + "The foot was placed in a heavy compressive bandage for the next 2 weeks.", + "Ankle mobilization and stretching exercises were initiated as tolerated by the patient.", + "At his latest follow-up of 18 months, the patient reported to be pain free.", + "The patient displayed normal range of motion at the ankle joint compared to his non-operated, contra-lateral left foot.", + "The patient consented to participating in this study." + ], + "summary": "An 18-year-old patient with an injured right ankle was referred to our clinic after failed attempts to resolve his symptoms conservatively. Based on our initial clinical and radiographic examination, the patient was continued on a conservative treatment plan assuming, it was a case of unsuccessful fracture union. After almost a year of failed conservative treatments, surgery was offered to the patient, with the understanding that the bone fragment might either be fused or completely removed based on intraoperative diagnosis. At surgery, it was observed that the bone fragment had the characteristic of an Os subtibiale. It presented as a round, smooth structure with well-formed cortical boundaries, and minimal attachment to the distal tibia. A diagnosis of symptomatic Os subtibiale was made intraoperatively, which was then successfully excised using standard orthopedic instrumentation. The patient healed uneventfully and reported a pain free, normal ankle range of motion at latest follow-up of 18 months.", + "summary_subclaims": [ + "The patient was referred to the clinic after failed attempts to resolve symptoms conservatively.", + "The patient was continued on a conservative treatment plan assuming it was a case of unsuccessful fracture union.", + "After almost a year of failed conservative treatments, surgery was offered.", + "Surgery was offered with the understanding that the bone fragment might either be fused or completely removed based on intraoperative diagnosis.", + "At surgery, it was observed that the bone fragment had the characteristic of an Os subtibiale.", + "The bone fragment presented as a round, smooth structure with well-formed cortical boundaries.", + "The bone fragment had minimal attachment to the distal tibia.", + "A diagnosis of symptomatic Os subtibiale was made intraoperatively.", + "The Os subtibiale was successfully excised using standard orthopedic instrumentation.", + "The patient healed uneventfully.", + "The patient reported a pain free, normal ankle range of motion at latest follow-up of 18 months." + ] + }, + { + "id": "multiclinsum_test_2836_en.txt", + "fulltext": "The patient’s father provided written consent to the use the patient’s medical information for research and publication.\nA 1-year-old girl (weight 10 kg) had suffered from a cough with sputum production for more than 2 days. She had a medical history of having swallowed a TFB 2 days earlier. The physical examination was normal, except for a wheezing sound in the right lung. A chest computed tomography scan revealed an 8 × 4 × 21 mm3 mass in the trachea near the carina, which given the patient’s history, was suggestive of the diagnosis of a TFB aspiration. After careful preoperative preparation, we scheduled the patient to undergo an emergency rigid tracheobronchoscopy to remove the TFB under general anesthesia. In order to keep the patient in spontaneous breathing, the combination of intravenous and inhalant anesthesia with propofol, fentanyl, and sevoflurane was planned to be administered. In the operating room, standard monitoring was installed, including SpO2, noninvasive blood pressure, and an electrocardiogram. Before administration of anesthesia, the child was premedicated with atropine (0.1 mg) and dexamethasone (2 mg)intravenously. Then anesthesia induction was performed with 8% sevoflurane carried by 6 L/min oxygen flow. After the patient became unconscious, anesthesia was maintained with 3–5% sevoflurane and 1 L/min oxygen flow for more than 5 min. Before rigid tracheobronchoscopy introduced into the trachea, the child received propofol (20 mg) and fentanyl (10 μg) intravenously to deepen the anesthesia. After 1–2 min, when her lower jaw was flabby, the surgeon introduced a LTA applicator into the trachea under the guidance of rigid tracheobronchoscopy, and then sprayed topical 1% lidocaine on the surfaces of the vocal cords and trachea. After the surgeon applied the topical anesthetic to the trachea, the girl suddenly suffered from bucking, which made it difficult to withdraw the LTA applicator. The surgeon quickly examined the opening of the main trachea using rigid tracheobronchoscopy, and found the TFB had migrated to the subglottic region against the LTA applicator. In this situation, manual ventilation became impossible and within half a minute, the patient’s SpO2 decreased to 91% and her heart rate dropped from 150 to 100 bpm. We administered an intravenous injection of atropine (0.3 mg) and succinylcholine (10 mg). Meanwhile, the surgeon tried to free the TFB by pushing it back into the trachea, after which the LTA kit was easily withdrawn. We then mask-ventilated the lungs successfully. The patient’s SpO2 quickly increased to 97% and her heart rate rose to 140 bpm. After deepening the anesthesia with propofol (20 mg) intravenously, the surgeon successfully grabbed and removed the TFB under jet ventilation . Afterwards, the girl’s condition improved quickly and she recovered uneventfully. She was discharged from the hospital 2 days later without complications.", + "fulltext_subclaims": [ + "The patient’s father provided written consent to the use the patient’s medical information for research and publication.", + "The patient was a 1-year-old girl with a weight of 10 kg.", + "The patient had suffered from a cough with sputum production for more than 2 days.", + "The patient had a medical history of having swallowed a TFB 2 days earlier.", + "The physical examination was normal, except for a wheezing sound in the right lung.", + "A chest computed tomography scan revealed an 8 × 4 × 21 mm3 mass in the trachea near the carina.", + "Given the patient’s history, the mass was suggestive of the diagnosis of a TFB aspiration.", + "The patient was scheduled to undergo an emergency rigid tracheobronchoscopy to remove the TFB under general anesthesia.", + "The combination of intravenous and inhalant anesthesia with propofol, fentanyl, and sevoflurane was planned to be administered.", + "In the operating room, standard monitoring was installed, including SpO2, noninvasive blood pressure, and an electrocardiogram.", + "Before administration of anesthesia, the child was premedicated with atropine (0.1 mg) and dexamethasone (2 mg) intravenously.", + "Anesthesia induction was performed with 8% sevoflurane carried by 6 L/min oxygen flow.", + "After the patient became unconscious, anesthesia was maintained with 3–5% sevoflurane and 1 L/min oxygen flow for more than 5 min.", + "Before rigid tracheobronchoscopy was introduced into the trachea, the child received propofol (20 mg) and fentanyl (10 μg) intravenously to deepen the anesthesia.", + "After 1–2 min, when her lower jaw was flabby, the surgeon introduced a LTA applicator into the trachea under the guidance of rigid tracheobronchoscopy.", + "The surgeon sprayed topical 1% lidocaine on the surfaces of the vocal cords and trachea.", + "After the surgeon applied the topical anesthetic to the trachea, the girl suddenly suffered from bucking, which made it difficult to withdraw the LTA applicator.", + "The surgeon quickly examined the opening of the main trachea using rigid tracheobronchoscopy.", + "The surgeon found the TFB had migrated to the subglottic region against the LTA applicator.", + "Manual ventilation became impossible.", + "Within half a minute, the patient’s SpO2 decreased to 91% and her heart rate dropped from 150 to 100 bpm.", + "An intravenous injection of atropine (0.3 mg) and succinylcholine (10 mg) was administered.", + "The surgeon tried to free the TFB by pushing it back into the trachea.", + "After the TFB was pushed back into the trachea, the LTA kit was easily withdrawn.", + "We then mask-ventilated the lungs successfully.", + "The patient’s SpO2 quickly increased to 97% and her heart rate rose to 140 bpm.", + "After deepening the anesthesia with propofol (20 mg) intravenously, the surgeon successfully grabbed and removed the TFB under jet ventilation.", + "The patient’s condition improved quickly and she recovered uneventfully.", + "She was discharged from the hospital 2 days later without complications." + ], + "summary": "A 1-year-old girl was undergoing TFB removal. After the surgeon completed the tracheal surface anesthesia, the girl suddenly suffered from bucking, leading to the dislodgment of the TFB to the subglottic region, complicating the withdrawal of the LTA applicator. At the same time, the girl's oxygen saturation (SpO2) decreased to 91% and her heart rate dropped from 150 to 100 bpm. Atropine and succinylcholine were administered intravenously immediately, then the surgeon tried to free the TFB by pushing it back into the trachea, after which the LTA applicator was easily withdrawn, and TFB was removed successfully. The girl was discharged from hospital without any complications 2 days later.", + "summary_subclaims": [ + "The patient was a 1-year-old girl.", + "The girl was undergoing TFB removal.", + "The surgeon completed the tracheal surface anesthesia.", + "The girl suddenly suffered from bucking.", + "The TFB was dislodged to the subglottic region.", + "The dislodgment complicated the withdrawal of the LTA applicator.", + "The girl's oxygen saturation decreased to 91%.", + "The girl's heart rate dropped from 150 to 100 bpm.", + "Atropine and succinylcholine were administered intravenously.", + "The surgeon tried to free the TFB by pushing it back into the trachea.", + "The LTA applicator was easily withdrawn after the TFB was pushed back.", + "The TFB was removed successfully.", + "The girl was discharged from hospital without any complications.", + "The girl was discharged 2 days after the event." + ] + }, + { + "id": "multiclinsum_test_2511_en.txt", + "fulltext": "The patient was a 72-year-old male. He was referred for penile pain. He had a 4-year history of dialysis therapy under a diagnosis of diabetes mellitus, which had been made 11 years previously. No urine production was observed, and 4-hour hemodialysis was performed three times a week. He also had a history of acute myocardial infarction, lacunar infarction, hypothyroidism and diabetic retinal detachment. Insulin glargine, aspirin, furosemide, amezinium metilsulfate, levothyroxine sodium hydrate and allopurinol were administered for the respective diseases.\nPain of the glans had persisted for 10 days, but the patient was unable to confirm the site of pain due to blindness. On consultation at the previous hospital, necrosis of the glans was observed and he was referred to our department for treatment.\nHis height, body weight, blood pressure, pulse rate, and body temperature were 160 cm, 64 kg, 142/74 mmHg, 77/min, and 36.8°C, respectively.\nYellow and black necrosis of the entire glans with severe pain was noted , and purulent discharge with odor was observed. Ulcers of the bilateral lower limbs and right dorsal hand with irregular yellow necrosis, dark red spots, and black keratotic nodules were noted.\nLaboratory examination on admission demonstrated corrected Ca, IP, I-PTH, CRP, HbA1c, WBC, Hb, and PLT levels of 9.7 mg/dL, 7.4 mg/dL, 97 pg/mL, 11.5 mg/dL, 7.3%, 13 500/μL, 18.3 g/dL and 23.4 × 104/μL, respectively.\nPlain computed tomography of the thorax and abdomen revealed marked calcification involving the thoracoabdominal aorta to external/internal iliac arteries. Calcification of the dorsal artery of the penis and ectopic calcification of the corpus cavernosum were also observed . On urethroscopy, urethral stricture in the anterior urethra was noted, but the investigation was insufficient because it induced further penile pain. Blood flow examination in the penis using color Doppler ultrasound was not performed.\nAfter admission, lavage and debridement were performed based on a diagnosis of calciphylaxis or necrosis related to intravascular thrombus at the department of dermatology. However, pain control of the glans was poor and there was no reduction of necrosis. Partial penectomy was performed 8 days after admission. The glans was dissected at an area proximal to the coronary sulcus. There was no hemorrhage. The external urethral meatus was created by a standard procedure. After surgery, penile pain promptly subsided. Paleness in a portion of the surgical wound, purulent discharge and fever were observed, but perineal care, debridement and antimicrobial drug administration were carried out.\nPathological macroscopic findings included ulceration, necrosis and abscess formation. Microscopy demonstrated marked calcification of the media in the small arteries, and thickening of the intima and lumen stenosis was noted, suggesting calciphylaxis .\nThe patient was transferred to his previous dialysis hospital 34 days postoperatively, with improvement in his general condition. The course had been favorable based on postoperative follow-up, but he died of pneumonia 11 months after surgery.", + "fulltext_subclaims": [ + "The patient was a 72-year-old male.", + "He was referred for penile pain.", + "He had a 4-year history of dialysis therapy under a diagnosis of diabetes mellitus.", + "Diabetes mellitus had been made 11 years previously.", + "No urine production was observed.", + "4-hour hemodialysis was performed three times a week.", + "He also had a history of acute myocardial infarction.", + "He also had a history of lacunar infarction.", + "He also had a history of hypothyroidism.", + "He also had a history of diabetic retinal detachment.", + "Insulin glargine, aspirin, furosemide, amezinium metilsulfate, levothyroxine sodium hydrate and allopurinol were administered.", + "Pain of the glans had persisted for 10 days.", + "The patient was unable to confirm the site of pain due to blindness.", + "On consultation at the previous hospital, necrosis of the glans was observed.", + "He was referred to our department for treatment.", + "His height was 160 cm.", + "His body weight was 64 kg.", + "His blood pressure was 142/74 mmHg.", + "His pulse rate was 77/min.", + "His body temperature was 36.8°C.", + "Yellow and black necrosis of the entire glans with severe pain was noted.", + "Purulent discharge with odor was observed.", + "Ulcers of the bilateral lower limbs and right dorsal hand with irregular yellow necrosis, dark red spots, and black keratotic nodules were noted.", + "Corrected Ca was 9.7 mg/dL.", + "Corrected IP was 7.4 mg/dL.", + "Corrected I-PTH was 97 pg/mL.", + "CRP was 11.5 mg/dL.", + "HbA1c was 7.3%.", + "WBC was 13 500/μL.", + "Hb was 18.3 g/dL.", + "PLT was 23.4 × 104/μL.", + "Plain computed tomography of the thorax and abdomen revealed marked calcification involving the thoracoabdominal aorta to external/internal iliac arteries.", + "Calcification of the dorsal artery of the penis was observed.", + "Ectopic calcification of the corpus cavernosum was observed.", + "On urethroscopy, urethral stricture in the anterior urethra was noted.", + "The investigation was insufficient because it induced further penile pain.", + "Blood flow examination in the penis using color Doppler ultrasound was not performed.", + "After admission, lavage and debridement were performed.", + "The diagnosis was calciphylaxis or necrosis related to intravascular thrombus.", + "Pain control of the glans was poor.", + "There was no reduction of necrosis.", + "Partial penectomy was performed 8 days after admission.", + "The glans was dissected at an area proximal to the coronary sulcus.", + "There was no hemorrhage.", + "The external urethral meatus was created by a standard procedure.", + "After surgery, penile pain promptly subsided.", + "Paleness in a portion of the surgical wound was observed.", + "Purulent discharge was observed.", + "Fever was observed.", + "Perineal care, debridement and antimicrobial drug administration were carried out.", + "Pathological macroscopic findings included ulceration, necrosis and abscess formation.", + "Microscopy demonstrated marked calcification of the media in the small arteries.", + "Thickening of the intima and lumen stenosis was noted.", + "Calciphylaxis was suggested.", + "The patient was transferred to his previous dialysis hospital 34 days postoperatively.", + "The course had been favorable based on postoperative follow-up.", + "He died of pneumonia 11 months after surgery." + ], + "summary": "The patient was a 72-year-old male. He was referred for penile pain. He had a 4-year history of dialysis therapy under a diagnosis of diabetic nephropathy. Black and yellow necrosis was observed involving the entire glans, accompanying severe pain. Computed tomography revealed marked calcification involving the thoracoabdominal aorta to iliac arteries, the dorsal artery of the penis and the corpus cavernosum, leading to a diagnosis of calciphylaxis. Penile pain gradually exacerbated and partial penectomy was performed. After surgery, penile pain promptly subsided. Pathological examination confirmed marked calcification of the microvascular wall and narrowing of the lumen.", + "summary_subclaims": [ + "The patient was a 72-year-old male.", + "He was referred for penile pain.", + "He had a 4-year history of dialysis therapy under a diagnosis of diabetic nephropathy.", + "Black and yellow necrosis was observed involving the entire glans.", + "Computed tomography revealed marked calcification involving the thoracoabdominal aorta to iliac arteries.", + "Computed tomography revealed marked calcification involving the dorsal artery of the penis.", + "Computed tomography revealed marked calcification involving the corpus cavernosum.", + "The diagnosis was calciphylaxis.", + "Penile pain gradually exacerbated.", + "Partial penectomy was performed.", + "After surgery, penile pain promptly subsided.", + "Pathological examination confirmed marked calcification of the microvascular wall.", + "Pathological examination confirmed narrowing of the lumen." + ] + }, + { + "id": "multiclinsum_test_1084_en.txt", + "fulltext": "A 32-year-old Chinese female was admitted to Sichuan University West China Hospital with a 6-month history of upper abdominal pain. She denied previous radiotherapy or industrial chemical exposure. She had one previous pregnancy and and gave birth to a boy. In addition, she denied previous hormonal treatments and contraceptives. She was found to have viral hepatitis B for 6 years and had not received any treatment. Besides, she was healthy with no relevant medical or family history of diseases, such as hypertension or diabetes, and no history of smoking or alcohol consumption. Physical examination was unremarkable. A blood count showed Hb 14.2 g/dl (13–17.5), white blood cells 7.12×109/L (3.5-9.5), platelets 249×109/L (100–300), total bilirubin 12.5 umol/L (5.0-28), and AST 35 IU/L (<50). Serological testing for tumor marker of carcinoembryonic antigen (CEA) was 5.54 ng/ml (CEA ≥ 3.4 ng/ml was defined as abnormal) and hepatitis B surface antigen (HBsAg) was positive. The hepatitis B virus DNA (HBV-DNA) was less than 1×102 IU/ml (HBV-DNA ≥ 1×102 IU/ml was defined as HBV infection active), suggesting that HBV infection was inactive. The cancer antigen19-9 (CA19-9 ≥ 30 U/ml was defined as abnormal), CA125 (CA125 ≥ 24 U/ml was defined as abnormal) and α-fetoprotein (AFP≥ 7 ng/ml was defined as abnormal) was 25.6 U/ml, 13.3U/ml and 3.37, respectively. Abdominal computed tomography (CT) showed the lesion in the left lobe of liver was detected, and no tumor was detected in any other organs . Magnetic resonance imaging (MRI) of the upper abdomen was performed in our hospital for further diagnosis. The MRI showed a 1.1×1.3 cm lesion in the left lobe of liver, appearing low signal intensity on T1-weighted images and high signal intensity on T2-weighted images . Due to the similar appearance, hepatocellular carcinoma (HCC) was considered for preoperative diagnosis. The patient eventually underwent a laparoscopic liver resection of the left lobe. Macroscopically, the tumor was a yellowish solid mass with a diameter of 12mm. Microscopically, the lesion composed of undifferentiated epithelial cells with some atypical glands, and significant lymphocytic infiltration . The epithelial tumor cells were featured by eosinophilic cytoplasm with large nuclei and prominent nucleoli. EBVencoded RNA (EBER) in situ hybridization was positive in tumor tissues. In addition, immunohistochemical analysis showed the lymphatic tissue positive for CD20 (B-cells, ), CD3 (T-cells, ), Ki-67 and negative for IgG4. Meanwhile, tumor cells positive for CK7 , and negative for CK20, supporting the diagnosis of LEL-ICC.\nPost-operative recovery of the patient was well. The patient was discharged on postoperative day 5 with good general condition. The laboratory parameters were normal and we recommended regular follow-up in the outpatient clinic.\nPatients monitored the disease progression at the outpatient of our hospital every 3 months in the first two years after surgery and every 6 months thereafter via blood examination, ultrasonography (US), CT, and MRI. The systematic update of patients’survival information was performed once a year. The last outpatient follow-up was in August 2022, and the tumor markers were normal. The patient was free from tumor recurrence after a 28 months follow-up .", + "fulltext_subclaims": [ + "The patient was a 32-year-old Chinese female.", + "She was admitted to Sichuan University West China Hospital.", + "She had a 6-month history of upper abdominal pain.", + "She denied previous radiotherapy.", + "She denied previous industrial chemical exposure.", + "She had one previous pregnancy.", + "She gave birth to a boy.", + "She denied previous hormonal treatments.", + "She denied previous contraceptive use.", + "She had viral hepatitis B for 6 years.", + "She had not received any treatment for hepatitis B.", + "She was healthy with no relevant medical history.", + "She had no family history of hypertension.", + "She had no family history of diabetes.", + "She had no history of smoking.", + "She had no history of alcohol consumption.", + "Physical examination was unremarkable.", + "Hb was 14.2 g/dl.", + "White blood cells were 7.12×109/L.", + "Platelets were 249×109/L.", + "Total bilirubin was 12.5 umol/L.", + "AST was 35 IU/L.", + "CEA was 5.54 ng/ml.", + "CEA ≥ 3.4 ng/ml was defined as abnormal.", + "HBsAg was positive.", + "HBV-DNA was less than 1×102 IU/ml.", + "HBV-DNA ≥ 1×102 IU/ml was defined as HBV infection active.", + "CA19-9 was 25.6 U/ml.", + "CA19-9 ≥ 30 U/ml was defined as abnormal.", + "CA125 was 13.3 U/ml.", + "CA125 ≥ 24 U/ml was defined as abnormal.", + "AFP was 3.37 ng/ml.", + "AFP ≥ 7 ng/ml was defined as abnormal.", + "Abdominal CT showed a lesion in the left lobe of the liver.", + "No tumor was detected in any other organs.", + "MRI showed a 1.1×1.3 cm lesion in the left lobe of the liver.", + "The lesion appeared low signal intensity on T1-weighted images.", + "The lesion appeared high signal intensity on T2-weighted images.", + "Hepatocellular carcinoma was considered for preoperative diagnosis.", + "The patient underwent laparoscopic liver resection of the left lobe.", + "Macroscopically, the tumor was a yellowish solid mass with a diameter of 12mm.", + "Microscopically, the lesion composed of undifferentiated epithelial cells with some atypical glands.", + "There was significant lymphocytic infiltration.", + "The epithelial tumor cells were featured by eosinophilic cytoplasm with large nuclei and prominent nucleoli.", + "EBER in situ hybridization was positive in tumor tissues.", + "Immunohistochemical analysis showed lymphatic tissue positive for CD20.", + "Immunohistochemical analysis showed lymphatic tissue positive for CD3.", + "Immunohistochemical analysis showed lymphatic tissue positive for Ki-67.", + "Immunohistochemical analysis showed lymphatic tissue negative for IgG4.", + "Tumor cells were positive for CK7.", + "Tumor cells were negative for CK20.", + "The diagnosis was LEL-ICC.", + "The patient was discharged on postoperative day 5.", + "The patient had good general condition at discharge.", + "Laboratory parameters were normal at discharge.", + "The patient was recommended for regular follow-up.", + "The patient was monitored every 3 months in the first two years after surgery.", + "The patient was monitored every 6 months thereafter.", + "Monitoring included blood examination.", + "Monitoring included ultrasonography.", + "Monitoring included CT.", + "Monitoring included MRI.", + "Systematic update of survival information was performed once a year.", + "The last outpatient follow-up was in August 2022.", + "Tumor markers were normal at the last follow-up.", + "The patient was free from tumor recurrence after a 28 months follow-up." + ], + "summary": "We presented a case of a 32-year-old Chinese female with LEL-ICC. She had a 6-month history of upper abdominal pain. The magnetic resonance imaging (MRI) showed a 1.1× 1.3 cm lesion in the left lobe of liver, appearing low signal intensity on T1-weighted images and high signal intensity on T2-weighted images. The patient underwent laparoscopic left lateral sectionectomy. The postoperative histopathologic and immunohistochemical examinations results allowed for the definitive diagnosis of LEL-ICC. The patient was free from tumor recurrence after a 28 months follow-up.", + "summary_subclaims": [ + "The patient was a 32-year-old Chinese female.", + "The patient had a 6-month history of upper abdominal pain.", + "The MRI showed a 1.1× 1.3 cm lesion in the left lobe of the liver.", + "The lesion appeared low signal intensity on T1-weighted images.", + "The lesion appeared high signal intensity on T2-weighted images.", + "The patient underwent laparoscopic left lateral sectionectomy.", + "The postoperative histopathologic and immunohistochemical examinations results allowed for the definitive diagnosis of LEL-ICC.", + "The patient was free from tumor recurrence after a 28 months follow-up." + ] + }, + { + "id": "multiclinsum_test_2633_en.txt", + "fulltext": "A 60 years old Caucasian woman was admitted to the Emergency Department of our Hospital because of ascites and abdominalgia. Twenty years earlier she was diagnosed with breast cancer, subjected to mastectomy and then treated with several chemotherapy lines, including the inhibitor of vascular endothelial growth factor A Bevacizumab, hormonal therapy and local radiotherapy. About 5 months before the admission, she developed seizures and sudden cognitive impairment, with loss of contact: a MRI revealed cranial and cerebral metastasis. An antiepileptic drug Levetiracetam was started as well panencephalic radiotherapy was given for five days. Chemotherapy was also administered with resolution of symptoms and regression of metastasis. One month before the hospitalization, she developed lower limb deep vein thrombosis, so she started fondaparinux as anticoagulation therapy. The patient continued its oncological follow-up schedule of a stage IV breast cancer, with multiple liver, pleural, pulmonary and bone metastasis, treated with Palbociclib, anti-CDK4 and 6 antagonist and Fulvestrant, an estrogen receptor antagonist. At two follow-up visits during the 4 weeks prior to admission to the Emergency Department because of low circulating serum magnesium levels, magnesium and potassium salts supplementation was reported and then suspended due to the appearance of abdominal pain. She was sent to the Emergency department by the oncologist because of abdominalgia associated to nausea and vomiting. She has been treated with a proton pump inhibitor for at least 6 months because of heartburn, regurgitation, and symptoms related to gastroesophageal reflux disease. An abdominal ultrasound highlighted abundant ascites. She was vigilant and collaborating, without alteration on neurological exam. Her vital parameters were normal, and laboratory tests showed mild anemia (Hemoglobin 10.6 g/dl, hematocrit 32%), no renal (creatinine 0.4 mg/dL) or hepatic (GOT 21 U/L; GPT 13 U/L; total bilirubin 0.4 mg/dL, albumin 3.2 g/dL) impairment and a moderate increase in C reactive protein (63 mg/L; normal values < 5 mg/L). Plasma sodium (135 mEq/L), potassium (3.9 mEq/L), chloride (98 mEq/L), calcium (8.2 mg/dL) and phosphate (4.0 mg/dL) concentration were normal, whereas magnesium levels were at the lower limit (1.8 mg/dL). Within the normal range was also pH and bicarbonate. Coagulation was normal, except for a significant increase of d-dimer. On physical examination, she had ascites and abdominalgia without breathing impairment. She felt nausea and vomit; symptomatic therapy with metoclopramide was given and a parenteral nutrition infusion with Olimel N4 (1500 ml/day, Glucose 112,5 g, Lipids 45 g, Amino-acids 38 g, Nitrogen 6 g; sodium 21 mEq/L, potassium 16 mEq/L, Mg 2.2 mEq/L, osmolarity 760 mOsm/L) was started. She was treated parenterally with loop of Henle diuretic therapy, furosemide associated with potassium sparing diuretic canrenoate, associated to water restriction. An abundant diuretic response and the reduction of ascites was observed in the 48 hours following, with a significant weight loss and an almost complete resolution of the abdominalgia. No changes in blood pressure or heart rate were measured. She suddenly presented confused and disoriented. She was not able to attempt a simple order and she complained headache. Her blood pressure was still normal and the neurological exam did not show any focal or lateral abnormality. Ammonium blood levels were normal (37 uM/L, normal values between 10-50). An urgent cerebral tomography was performed, showing a diffuse cerebral edema (,ABC). Patient neurological condition rapidly got worse, till vigil coma, with loss of interaction ability, while her vital parameters (blood pressure, heart rate and peripheral oxygen saturation) remained normal. Treatment with intravenous desametasone (8 mg twice a day) and mannitol (mannitol 18%, 100 ml four times per day followed by 50 ml four times per day), associated with magnesium sulphate (40 mEq in saline solution 250 ml per day in 6-hour infusion period) was immediately started and continued for three days. A cerebral MRI was urgently performed showing diffuse increase in signal alteration of the periventricular, deep and sub-cortical white matter in parieto-occipital region of the two sides, as from leukoencephalopathy, also in relation to post-radiotherapy modifications. venous thrombosis of the distal segment of the transverse sinus and of part of the left sigmoid sinus .\nShe continued subcutaneous Fondaparinux at anticoagulating dose (7,5 mg/die) while Palbociclib and Fulvestrant were discontinued. Anti-edema (desametasone and mannitol) treatment as well magnesium sulphate infusion were continued. Her clinical condition rapidly improved with resolution of the acute episode.\nA brain MRI was performed after 10 days, showing less but still persistent bilateral parieto-temporal-occipital vasogenic edema, partial resolution of the cerebral vein thrombosis, but evidencing the presence of few micro-haemorrhages in left temporal and parietal site .\nPatient neurological status completely recovered and after 2 weeks, she was discharged with the diagnosis of PRES.\nAt a MRI brain scan, performed the following month, a reduction of the vasogenic edema but a persistent even if reduced left transverse sinus thrombosis . After a month, she was admitted to the hospital because of severe respiratory distress due to pneumonia and after three days she passed away.", + "fulltext_subclaims": [ + "The patient was a 60 years old Caucasian woman.", + "She was admitted to the Emergency Department because of ascites and abdominalgia.", + "Twenty years earlier she was diagnosed with breast cancer.", + "She was subjected to mastectomy.", + "She was treated with several chemotherapy lines, including Bevacizumab.", + "She was treated with hormonal therapy.", + "She was treated with local radiotherapy.", + "About 5 months before the admission, she developed seizures and sudden cognitive impairment.", + "A MRI revealed cranial and cerebral metastasis.", + "An antiepileptic drug Levetiracetam was started.", + "Panencephalic radiotherapy was given for five days.", + "Chemotherapy was also administered.", + "Symptoms resolved.", + "Metastasis regressed.", + "One month before the hospitalization, she developed lower limb deep vein thrombosis.", + "She started fondaparinux as anticoagulation therapy.", + "She continued its oncological follow-up schedule of a stage IV breast cancer.", + "She had multiple liver, pleural, pulmonary and bone metastasis.", + "She was treated with Palbociclib.", + "She was treated with Fulvestrant.", + "At two follow-up visits during the 4 weeks prior to admission, magnesium and potassium salts supplementation was reported.", + "Magnesium and potassium salts supplementation was then suspended due to the appearance of abdominal pain.", + "She was sent to the Emergency department by the oncologist because of abdominalgia associated to nausea and vomiting.", + "She was treated with a proton pump inhibitor for at least 6 months.", + "An abdominal ultrasound highlighted abundant ascites.", + "She was vigilant and collaborating.", + "Her vital parameters were normal.", + "Laboratory tests showed mild anemia.", + "Plasma sodium was 135 mEq/L.", + "Plasma potassium was 3.9 mEq/L.", + "Plasma magnesium levels were at the lower limit.", + "Coagulation was normal, except for a significant increase of d-dimer.", + "On physical examination, she had ascites and abdominalgia.", + "She felt nausea and vomit.", + "Symptomatic therapy with metoclopramide was given.", + "A parenteral nutrition infusion with Olimel N4 was started.", + "She was treated parenterally with loop of Henle diuretic therapy.", + "An abundant diuretic response and the reduction of ascites was observed in the 48 hours following.", + "She suddenly presented confused and disoriented.", + "An urgent cerebral tomography was performed, showing a diffuse cerebral edema.", + "Treatment with intravenous desametasone and mannitol was immediately started.", + "A cerebral MRI showed diffuse increase in signal alteration of the periventricular, deep and sub-cortical white matter.", + "Venous thrombosis of the distal segment of the transverse sinus and of part of the left sigmoid sinus was observed.", + "She continued subcutaneous Fondaparinux at anticoagulating dose.", + "Palbociclib and Fulvestrant were discontinued.", + "Anti-edema treatment as well magnesium sulphate infusion were continued.", + "Her clinical condition rapidly improved with resolution of the acute episode.", + "A brain MRI showed less but still persistent bilateral parieto-temporal-occipital vasogenic edema.", + "Partial resolution of the cerebral vein thrombosis was observed.", + "Few micro-haemorrhages in left temporal and parietal site were evidenced.", + "Patient neurological status completely recovered.", + "After 2 weeks, she was discharged with the diagnosis of PRES.", + "A brain MRI scan showed a reduction of the vasogenic edema.", + "A persistent even if reduced left transverse sinus thrombosis was observed.", + "After a month, she was admitted to the hospital because of severe respiratory distress due to pneumonia.", + "After three days she passed away." + ], + "summary": "A woman affected by stage IV breast cancer with lower extremity deep vein thrombosis treated with low-molecular-weight-heparin, currently in therapy with Palbociclib/Fulvestrant (antiCDK4 and 6/estrogen receptor antagonist) but previously treated with several other chemotherapy lines (including VEGF inhibitor bevacizumab), was admitted to our Internal Medicine department because of ascites and abdominal pain. She was treated with diuretics (and paracentesis). Recently (six-month earlier) a pan-encephalic radiotherapy was done because of brain and skull metastasis. Among blood tests, low serum levels of hypomagnesemia were observed. She developed PRES that rapidly progressed to lethargy, unresponsiveness till coma without changes in blood pressure. Magnetic Resonance Imaging study showed bilateral parieto-occipital edema and a thrombosis of left transverse and sigmoid sinuses. Anti-edema therapy, intravenous supplementation of magnesium and decoagulation were started, with complete and rapid recovery (within 18 hours) of clinical and radiologic changes.", + "summary_subclaims": [ + "The patient is a woman with stage IV breast cancer.", + "She has lower extremity deep vein thrombosis.", + "She is currently being treated with Palbociclib/Fulvestrant.", + "She was previously treated with several other chemotherapy lines.", + "She was admitted to the Internal Medicine department because of ascites and abdominal pain.", + "She was treated with diuretics.", + "A pan-encephalic radiotherapy was done six months earlier.", + "Low serum levels of hypomagnesemia were observed.", + "She developed PRES.", + "Magnetic Resonance Imaging showed bilateral parieto-occipital edema.", + "Anti-edema therapy was started.", + "Intravenous supplementation of magnesium was started.", + "Decoagulation was started.", + "Clinical and radiologic changes showed complete and rapid recovery within 18 hours." + ] + }, + { + "id": "multiclinsum_test_2120_en.txt", + "fulltext": "A 36-year-old woman presented at our hospital with a palpable mass at the external left breast quadrants in December 2011. The patient underwent breast ultrasound and breast magnetic resonance imaging (MRI) that confirmed the presence of a nodular formation of about 5 cm. In addition, at least three lymphadenopathies with eccentric hilum were identified in the left axillary cable, and remote staging tests were negative. In January 2012, breast biopsy diagnosed an infiltrating ductal carcinoma of the breast, grade 3, estrogen receptor (ER)-positive (90%), progesterone receptor (PR)-positive (36%), HER2-positive (3+ by IHC), and MIB-1 36%. The pathological nature of lymphadenopathies was confirmed by fine-needle aspiration.\nFrom January 2012 to April 2012, the patient received neoadjuvant chemotherapy with docetaxel (100 mg/m2) and trastuzumab (8 mg/kg loading dose, followed by 6 mg/kg) every three weeks for four cycles followed by cyclophosphamide (600 mg/m2) and doxorubicin (60 mg/m2) every three weeks for four cycles. The second cycle of chemotherapy was delayed due to hypertransaminasemia grade 2 (according to common terminology criteria for adverse events (CTCAE) version 5.0), treated with glutathione and prednisone 25 mg/die for five days. Treatment with docetaxel was resumed at 25% reduced dose, reporting only grade 1 hypertransaminasemia during subsequent cycles. In August 2012, the patient underwent bilateral mastectomy and axillary node resection with a partial response to neoadjuvant chemotherapy (ypT1c ypN1 Mx).\nFrom October 2012 to April 2013, the patient continued adjuvant therapy with trastuzumab administered subcutaneously (600 mg) every three weeks to complete one year of treatment and hormone therapy with tamoxifene plus luteinizing hormone-releasing hormone (LHRH) inhibitor since September 2012.\nIn January 2014, after the finding of thickening of the subcutaneous areola, the patient underwent surgical radical removal of the nipple and left areola. The diagnosis was intraductal carcinoma of cribriform type in galactophore ducts of high-grade sec. WHO 2012 and Paget’s disease, ER 90% PgR negative.\nShe continued regular clinico-radiological follow-up, negative for locoregional and distance recurrence, until January 2016 when a total body contrast-enhanced computed tomography (CECT) scan and an 18-fluor-fluorodeoxyglucose positron emission tomography-computed tomography (18F-FDG PET/CT) confirmed the presence of bilateral pulmonary, mediastinal pathological lymph nodes and bone metastases. According to the disease stage, biomolecular tumor characteristics, and clinical conditions (PS 0 sec. ECOG), in January 2016, the patient started first-line therapy with pertuzumab plus trastuzumab and docetaxel every three weeks at standard doses. She reassumed the same regimen up to four courses and then she continued with dual HER2-blockage for a further three cycles. The CECT scan after three courses of treatment showed a partial response, but after the second cycle the patient showed grade 2 mucositis and grade 3 hypertransaminasemia, treated with glutathione and prednisone 25 mg/die for five days, and the third cycle was delayed. Antigens of hepatitis were tested and resulted negative.\nIn August 2016, an 18F-FDG PET/CT revealed lymph node and bone progression disease. Thus, she started second-line therapy with T-DM1 at 3.6 mg/kg every three weeks with concurrent denosumab every four weeks. From August 2016 to April 2018, she received 28 cycles. After the ninth cycle, due to the occurrence of grade 2 hypertransaminasemia, glutathione was introduced in chemotherapy regimens with the resolution of toxicity.\nIn April 2018, due to a lymph node and lung disease progression, the patient was enrolled in the phase III clinical trial SOPHIA (NCT02492711) and randomized to the control arm. The screening laboratory findings showed a grade 3 hypertransaminasemia that was treated with glutathione infusion. At the resolution of toxicity, since the patient had been randomized into the control arm, she began treatment with trastuzumab (8 mg/kg loading dose, followed by 6 mg/kg) and navelbine (25 mg/mq d1–8 every three weeks). The treatment was poorly tolerated with grade 4 neutropenia and grade 2 anemia after the first cycle and grade 4 neutropenia after the second cycle with 50% dose reduction and secondary prophylaxis with granulocyte colony-stimulating factor (G-CSF). Due to hematological toxicities, she continued treatment without navelbine, and she received four courses with trastuzumab.\nIn October 2018, a further lymph node and lung disease progression was detected, and then she started fourth line with capecitabine (1000 mg/mq bid d1–14) plus lapatinib (1250 mg once daily) every three weeks. The patient received IX cycle from November 2018 to June 2019. After the first cycle, she presented grade 1 hypertransaminasemia, which was resolved with glutathione infusion.\nAfter a further lymph node and lung disease progression, she received fifth-line therapy with nab-paclitaxel 260 mg/m2 and trastuzumab every three weeks with primary prophylaxis with G-CSF. She received nine courses from July 2019 to December 2019, and she presented only grade 1 hypertransaminasemia.\nDue to the evidence of complete response and the patient’s preference to discontinue alopecitizing chemotherapy, she continued treatment with trastuzumab alone until March 2020, when an 18F-FDG PET/CT revealed lymph node and lung relapse. Then, in April 2020, she started sixth-line therapy with gemcitabine 1000 mg/m2·d1, d8 plus trastuzumab 6 mg/kg every three weeks. After the first cycle, she presented grade 2 hypertransaminasemia and grade 2 thrombocytopenia, so she stopped the treatment; due to the occurrence of pain in the left arm (VAS 8), we prescribed oxycodone plus naloxone. At the fourth cycle, she showed grade 3 hypertransaminasemia, and we decided to reduce gemcitabine dose, but the toxicity persisted. Therefore, liver virology was tested again. Moreover, at this time point , since the new technology for DDGI had become available at our center, we evaluated her genomic polymorphisms, including genes encoding for the main drug metabolism enzymes, and simultaneously analyzed all her clinical, biochemical, and genomic data by using the new Drug-PIN system comprehensive approach ( (accessed on 31 March 2020)) In particular, for the SNP analysis, the patient’s DNA was extracted from samples of 5 mL of peripheral blood, using the automatic QIAsymphony system for the extraction of nucleic acid (Qiagen, Hilden, Germany), and then the latter was processed using a next-generation sequencing platform Ion Chef/Ion S5 system (Thermo Fisher Scientific, Waltham, MA, USA) according to the manufacturer’s instructions.\nDue to the results of the analysis , we decided to maintain the reduced dose of gemcitabine and to introduce glutathione as part of cancer treatment from the sixth cycle of chemotherapy.\nFrom August to December 2020, the patient received 25% reduced dose gemcitabine with four vials of glutathione, and she showed maximum grade 2 liver toxicity.\nIn December 2020, an 18F-FDG PET/CT evaluation revealed oligometastatic lymph node and bone progression; therefore, we decided to treat with local radiotherapy on sternal dumbbell and left later-cervical, supraclavicular, and retro-pectoral lymph nodes, maintaining the same chemotherapy regimen. Today, the treatment with gemcitabine and trastuzumab is still ongoing, and the patient has reported an overall survival (OS) of 111 months from first diagnosis and of 50 months from recurrence.", + "fulltext_subclaims": [ + "A 36-year-old woman presented at our hospital with a palpable mass at the external left breast quadrants in December 2011.", + "The patient underwent breast ultrasound and breast magnetic resonance imaging (MRI) that confirmed the presence of a nodular formation of about 5 cm.", + "At least three lymphadenopathies with eccentric hilum were identified in the left axillary cable.", + "Remote staging tests were negative.", + "In January 2012, breast biopsy diagnosed an infiltrating ductal carcinoma of the breast, grade 3.", + "Estrogen receptor (ER) was positive (90%).", + "Progesterone receptor (PR) was positive (36%).", + "HER2 was positive (3+ by IHC).", + "MIB-1 was 36%.", + "The pathological nature of lymphadenopathies was confirmed by fine-needle aspiration.", + "From January 2012 to April 2012, the patient received neoadjuvant chemotherapy with docetaxel (100 mg/m2) and trastuzumab (8 mg/kg loading dose, followed by 6 mg/kg) every three weeks for four cycles.", + "The second cycle of chemotherapy was delayed due to hypertransaminasemia grade 2.", + "Treatment with docetaxel was resumed at 25% reduced dose.", + "In August 2012, the patient underwent bilateral mastectomy and axillary node resection.", + "The patient had a partial response to neoadjuvant chemotherapy (ypT1c ypN1 Mx).", + "From October 2012 to April 2013, the patient continued adjuvant therapy with trastuzumab administered subcutaneously (600 mg) every three weeks.", + "The patient continued hormone therapy with tamoxifene plus luteinizing hormone-releasing hormone (LHRH) inhibitor since September 2012.", + "In January 2014, the patient underwent surgical radical removal of the nipple and left areola.", + "The diagnosis was intraductal carcinoma of cribriform type in galactophore ducts of high-grade sec. WHO 2012.", + "The diagnosis was Paget’s disease, ER 90% PgR negative.", + "She continued regular clinico-radiological follow-up, negative for locoregional and distance recurrence, until January 2016.", + "In January 2016, a total body contrast-enhanced computed tomography (CECT) scan and an 18-fluor-fluorodeoxyglucose positron emission tomography-computed tomography (18F-FDG PET/CT) confirmed the presence of bilateral pulmonary, mediastinal pathological lymph nodes and bone metastases.", + "In January 2016, the patient started first-line therapy with pertuzumab plus trastuzumab and docetaxel every three weeks at standard doses.", + "She reassumed the same regimen up to four courses and then continued with dual HER2-blockage for a further three cycles.", + "The CECT scan after three courses of treatment showed a partial response.", + "After the second cycle, the patient showed grade 2 mucositis and grade 3 hypertransaminasemia.", + "Antigens of hepatitis were tested and resulted negative.", + "In August 2016, an 18F-FDG PET/CT revealed lymph node and bone progression disease.", + "She started second-line therapy with T-DM1 at 3.6 mg/kg every three weeks with concurrent denosumab every four weeks.", + "From August 2016 to April 2018, she received 28 cycles.", + "After the ninth cycle, due to the occurrence of grade 2 hypertransaminasemia, glutathione was introduced in chemotherapy regimens with the resolution of toxicity.", + "In April 2018, due to a lymph node and lung disease progression, the patient was enrolled in the phase III clinical trial SOPHIA (NCT02492711) and randomized to the control arm.", + "The screening laboratory findings showed a grade 3 hypertransaminasemia that was treated with glutathione infusion.", + "At the resolution of toxicity, since the patient had been randomized into the control arm, she began treatment with trastuzumab (8 mg/kg loading dose, followed by 6 mg/kg) and navelbine (25 mg/mq d1–8 every three weeks).", + "The treatment was poorly tolerated with grade 4 neutropenia and grade 2 anemia after the first cycle.", + "Due to hematological toxicities, she continued treatment without navelbine, and she received four courses with trastuzumab.", + "In October 2018, a further lymph node and lung disease progression was detected, and then she started fourth line with capecitabine (1000 mg/mq bid d1–14) plus lapatinib (1250 mg once daily) every three weeks.", + "The patient received IX cycle from November 2018 to June 2019.", + "After the first cycle, she presented grade 1 hypertransaminasemia, which was resolved with glutathione infusion.", + "After a further lymph node and lung disease progression, she received fifth-line therapy with nab-paclitaxel 260 mg/m2 and trastuzumab every three weeks with primary prophylaxis with G-CSF.", + "She received nine courses from July 2019 to December 2019, and she presented only grade 1 hypertransaminasemia.", + "Due to the evidence of complete response and the patient’s preference to discontinue alopecitizing chemotherapy, she continued treatment with trastuzumab alone until March 2020.", + "In March 2020, an 18F-FDG PET/CT revealed lymph node and lung relapse.", + "In April 2020, she started sixth-line therapy with gemcitabine 1000 mg/m2·d1, d8 plus trastuzumab 6 mg/kg every three weeks.", + "After the first cycle, she presented grade 2 hypertransaminasemia and grade 2 thrombocytopenia, so she stopped the treatment.", + "Due to the occurrence of pain in the left arm (VAS 8), oxycodone plus naloxone was prescribed.", + "At the fourth cycle, she showed grade 3 hypertransaminasemia, and we decided to reduce gemcitabine dose, but the toxicity persisted.", + "Liver virology was tested again.", + "We evaluated her genomic polymorphisms, including genes encoding for the main drug metabolism enzymes.", + "We simultaneously analyzed all her clinical, biochemical, and genomic data by using the new Drug-PIN system comprehensive approach.", + "For the SNP analysis, the patient’s DNA was extracted from samples of 5 mL of peripheral blood.", + "The DNA was processed using a next-generation sequencing platform Ion Chef/Ion S5 system.", + "Due to the results of the analysis, we decided to maintain the reduced dose of gemcitabine and to introduce glutathione as part of cancer treatment from the sixth cycle of chemotherapy.", + "From August to December 2020, the patient received 25% reduced dose gemcitabine with four vials of glutathione, and she showed maximum grade 2 liver toxicity.", + "In December 2020, an 18F-FDG PET/CT evaluation revealed oligometastatic lymph node and bone progression.", + "We decided to treat with local radiotherapy on sternal dumbbell and left later-cervical, supraclavicular, and retro-pectoral lymph nodes, maintaining the same chemotherapy regimen.", + "Today, the treatment with gemcitabine and trastuzumab is still ongoing.", + "The patient has reported an overall survival (OS) of 111 months from first diagnosis.", + "The patient has reported an overall survival (OS) of 50 months from recurrence." + ], + "summary": "We present the case of a woman suffering from triple-positive breast cancer; she had early-stage disease at the onset and after four years developed metastatic disease. During her history, she presented different toxicities due to antineoplastic treatments. Particularly, hypertransaminasemia was found during every line of treatment. Nevertheless, we were able to guarantee the patient an excellent therapeutic adhesion thanks to the supportive treatments and the reduction of drug dosage. Moreover, we conducted a simultaneous analysis of the patient's biochemical and genomic data thanks to Drug-PIN software, and we found several significant SNPs of the main enzymes and transporters involved in drug metabolism.", + "summary_subclaims": [ + "The patient is a woman with triple-positive breast cancer.", + "She had early-stage disease at the onset.", + "After four years, she developed metastatic disease.", + "She presented different toxicities due to antineoplastic treatments.", + "Hypertransaminasemia was found during every line of treatment.", + "Supportive treatments and reduction of drug dosage allowed excellent therapeutic adhesion.", + "Drug-PIN software was used for a simultaneous analysis of the patient's biochemical and genomic data.", + "Several significant SNPs of the main enzymes and transporters involved in drug metabolism were found." + ] + }, + { + "id": "multiclinsum_test_1853_en.txt", + "fulltext": "A 47-year-old male presented to the Outpatient Department of our hospital with a complaint of experiencing a burning sensation during urination for the past 12 days. Additionally, he mentioned that urine dribbled out after he finished voiding, causing his undergarments to become soaked. He had no associated complains of increased urinary frequency, urgency, reddish discoloration of urine, fever, urinary incontinence, or flank pain. He had no history of diagnosed comorbidities like hypertension, diabetes mellitus, hyperlipidemia, or thyroid disease. However, the patient did mention experiencing recurrent urinary symptoms resembling the current episode for approximately the past 12 years.\nThe patient had an episode of severe lower abdominal pain and had previously undergone a cystoscopic litholapaxy procedure 5 years ago to remove calculus in the prostatic urethra. . He was advised for a computed tomography (CT) scan of the pelvis prior to the surgery but was unable to follow the recommendations due to his financial constraints. The patient underwent the procedure under spinal anesthesia. After proper positioning and ensuring anesthesia, the cystoscope was inserted and advanced into the prostatic urethra where the stone was visualized and fragmented and the fragments were flushed out by the use of saline irrigation. The postoperative course was uneventful.\nThe patient was born at home with no antenatal care visits attended by the mother. The patient vaguely recalled experiencing some urinary problems during childhood, but there were no documented records of those episodes. There was no known history of genital anomalies, difficulty in vision, developmental delay and behavioral disorders. No identifiable precipitating factor for the formation of renal calculus was found in the patient’s medical history.\nUpon physical examination no abnormalities were detected in the patient. A urine routine examination was requested, revealing 8–10 pus cells per high-power field. The results of the renal function test (RFT) were within normal limits. Abdominal and pelvic ultrasonography (USG) detected a cystic dilation of the distal part of the left ureter measuring 2.7×2.6 cm which raised concerns about a possible underlying abnormality . Based on the USG findings, a CT urography was conducted, which was now accessible in the rural setting, to obtain a more comprehensive evaluation of the condition. The CT urography results revealed a left intravesical ureterocele measuring 3.4×2.3 cm. Furthermore, it demonstrated a partial duplex collecting system in the left kidney, with the fusion of the upper and lower pole moiety observed at the level of the pelvic ureteric junction. Mild dilatation of the proximal ureter was also noted . He was then diagnosed with a UTI believed to be secondary to the underlying anatomical abnormality.\nA urine sample was collected for culture, and the patient received medical management for an UTI with antibiotics. He was also advised to drink plenty of fluids which led to an improvement in his current symptoms. The diagnosis was explained to him, and regular follow-up visits were scheduled to monitor for symptoms and assess his RFT and USG. After a thorough discussion of the available options, the patient consented to undergo an endoscopic incision of the ureterocele. Subsequently, a cystoscope-guided puncture of the ureterocele was successfully performed without encountering any intraoperative or postoperative complications. The most recent RFT report was within the normal range. The patient has diligently attended follow-up appointments since being informed about his cause of recurrent symptoms and the need to monitor him for future symptoms and hence has expressed willingness to undergo further interventions if necessary. The patient has been symptom-free since the endoscopic incision.", + "fulltext_subclaims": [ + "The patient is a 47-year-old male.", + "He presented with a burning sensation during urination for the past 12 days.", + "He mentioned that urine dribbled out after voiding, causing his undergarments to become soaked.", + "He had no associated complaints of increased urinary frequency.", + "He had no associated complaints of reddish discoloration of urine.", + "He had no history of diagnosed comorbidities like hypertension.", + "He had no history of diagnosed comorbidities like diabetes mellitus.", + "He had no history of diagnosed comorbidities like hyperlipidemia.", + "He had no history of diagnosed comorbidities like thyroid disease.", + "He mentioned experiencing recurrent urinary symptoms resembling the current episode for approximately the past 12 years.", + "He had an episode of severe lower abdominal pain.", + "He had previously undergone a cystoscopic litholapaxy procedure 5 years ago to remove calculus in the prostatic urethra.", + "He was advised for a computed tomography (CT) scan of the pelvis prior to the surgery.", + "He was unable to follow the recommendations due to financial constraints.", + "The patient underwent the procedure under spinal anesthesia.", + "The cystoscope was inserted and advanced into the prostatic urethra.", + "The stone was visualized and fragmented.", + "The fragments were flushed out by the use of saline irrigation.", + "The postoperative course was uneventful.", + "The patient was born at home with no antenatal care visits attended by the mother.", + "The patient vaguely recalled experiencing some urinary problems during childhood.", + "There were no documented records of those episodes.", + "There was no known history of genital anomalies.", + "There was no known history of developmental delay.", + "There was no known history of behavioral disorders.", + "No identifiable precipitating factor for the formation of renal calculus was found in the patient’s medical history.", + "Upon physical examination, no abnormalities were detected.", + "A urine routine examination was requested.", + "The urine routine examination revealed 8–10 pus cells per high-power field.", + "The results of the renal function test (RFT) were within normal limits.", + "Abdominal and pelvic ultrasonography detected a cystic dilation of the distal part of the left ureter measuring 2.7×2.6 cm.", + "The CT urography results revealed a left intravesical ureterocele measuring 3.4×2.3 cm.", + "The CT urography demonstrated a partial duplex collecting system in the left kidney.", + "The fusion of the upper and lower pole moiety was observed at the level of the pelvic ureteric junction.", + "Mild dilatation of the proximal ureter was also noted.", + "He was diagnosed with a UTI believed to be secondary to the underlying anatomical abnormality.", + "A urine sample was collected for culture.", + "The patient received medical management for an UTI with antibiotics.", + "He was advised to drink plenty of fluids.", + "This led to an improvement in his current symptoms.", + "The diagnosis was explained to him.", + "Regular follow-up visits were scheduled.", + "The patient consented to undergo an endoscopic incision of the ureterocele.", + "A cystoscope-guided puncture of the ureterocele was successfully performed.", + "No intraoperative complications were encountered.", + "No postoperative complications were encountered.", + "The most recent RFT report was within the normal range.", + "The patient has attended follow-up appointments since being informed about his cause of recurrent symptoms.", + "The patient has expressed willingness to undergo further interventions if necessary.", + "The patient has been symptom-free since the endoscopic incision." + ], + "summary": "The authors present a case of a newly diagnosed partial duplex collecting system of the left kidney and left intravesical ureterocele, which was diagnosed for the first time at the age of 47 years, along with a history of symptoms suggestive of recurrent urinary tract infection and a urethral calculus which was surgically managed 5 years ago.", + "summary_subclaims": [ + "The authors present a case of a newly diagnosed partial duplex collecting system of the left kidney.", + "The patient had a newly diagnosed left intravesical ureterocele.", + "The left intravesical ureterocele was diagnosed for the first time at the age of 47 years.", + "The patient had a history of symptoms suggestive of recurrent urinary tract infection.", + "The patient had a urethral calculus which was surgically managed 5 years ago." + ] + }, + { + "id": "multiclinsum_test_916_en.txt", + "fulltext": "We present a rare and interesting case of a 68-year-old White male with T4aN1bM0, stage III (AJCC 8th edition) squamous cell carcinoma of the thyroid. His past medical history included hypertension, prostate cancer treated with androgen deprivation therapy, external beam radiation therapy, and brachytherapy, and a benign parotid tumor status post-parotidectomy 20 years prior. He was retired from working in corporate management, and family history was significant for lung cancer in his father and breast cancer in a sister. Comorbid illnesses included gastrointestinal reflux disease, for which he took ranitidine 150 mg daily and omeprazole 20 mg daily; hypertension, for which he took lisinopril 12.5 mg daily; hyperlipidemia, for which he took atorvastatin 20 mg daily; and seasonal allergies and asthma, for which he took montelukast 150 mg daily and loratadine 10 mg daily. He was also using naproxen and cannabis for cancer-related pain at time of presentation. He was a lifelong non-smoker and did not drink alcohol to excess. He first noticed his right neck mass while shaving 3 months prior to presentation. He reported some mild pain with swallowing, weight loss of unknown amount, right neck sensitivity to light touch, increased hoarseness, and a raspy voice. He was initially diagnosed by his primary care physician as having lymphadenopathy secondary to a sinus infection and received two rounds of antibiotics. The mass failed to improve and, as a result, a fine needle aspiration of the lesion was performed. Evaluation of the biopsy material demonstrated dysmorphic cells containing cytoplasmic keratin, which stained positively for CK5/6, consistent with a squamous cell carcinoma. Monoclonal PAX-8 (Biocare Medical, BC12) staining was also focally positive . Subsequent laryngoscopy revealed no mucosal lesions, but right vocal cord paralysis was observed. A CT of the neck with contrast revealed a 4.8 cm peripherally enhancing hypodense mass with central necrosis lateral to the right hyoid bone, emanating from the thyroid gland . Multiple smaller nodular lesions within the prevertebral space, right paraesophageal region, and superior mediastinum were also identified. A staging PET scan showed a hypermetabolic right thyroid lobe with extensive conglomerate pathologic adenopathy at the right cervical lymph node chain, extending inferior to the right thoracic inlet, as well as a left retropharyngeal hypermetabolic lymph node, but no evidence of distant metastasis . On initial physical and neurologic examination, the oncology team noted a large, firm, fixed right medial neck mass without overlying skin changes, and a normal cranial nerve exam.\nThe patient’s case was discussed at the head and neck multidisciplinary tumor board, with a consensus opinion that this squamous cell carcinoma was indeed of thyroid origin. Extensive surgical resection including a laryngectomy, thyroidectomy, and reconstruction followed by adjuvant chemoradiation as a potential curative course was recommended. However, due to the morbidity and lifestyle implications associated with surgery, the patient declined surgery and instead chose to pursue concurrent chemoradiation with weekly chemotherapy.\nIntensity modulated radiation therapy (IMRT) was used to treat the right thyroid mass to 70 Gy in 35 fractions at 200 cGy per fraction, as well as bilateral retropharyngeal nodes cervical neck nodal levels IB, II, III, IV, and V to 63 Gy in 35 fractions at 180 cGy per fraction . The patient completed radiation with weekly concurrent carboplatin-paclitaxel over 7 weeks. During treatment, he developed grade 2 fatigue, grade 2 mucositis, grade 2 dermatitis, grade 3 dysphagia, and grade 3 dry mouth with thickened secretions with excessive mucus. The skin desquamation was treated with silver sulfadiazine and mineral oil-hydrophil petrolat. A percutaneous endoscopic gastrostomy (PEG) tube was placed during the first week of treatment due to nutrition and oral intake difficulties at baseline, and the patient lost less than 15 lbs throughout the treatment. Long-term toxicity was significant for chronic xerostomia and dysphagia, requiring a permanent gastrostomy tube. He also developed treatment-related hypothyroidism and was started on levothyroxine approximately 3 months after completion of treatment, when his thyroid-stimulating hormone (TSH) was found to have gone up from 1.63 (baseline, normal) to 21 mIU/mL (elevated).\nAfter receiving concurrent chemoradiation, the patient underwent two additional cycles of high-dose carboplatin–paclitaxel every 3 weeks. Follow-up imaging after concurrent chemoradiation suggested a partial therapeutic response. PET (18-fluorodeoxyglucose/18-FDG)/CT of the neck demonstrated that the thyroid mass had decreased in size from 5.0 × 5.2 cm, with maximum standardized uptake values (SUV) of 35.3, to 3.8 × 2.1 cm, with maximum SUV of 19.4 . This was also apparent on physical examination, where the tumor was smaller, softer, and less tender to palpation. The right and left neck lymph nodes were also notably smaller and demonstrated less PET-avidity. Imaging of the chest, however, revealed pulmonary metastases up to 9 mm in size, as well as multiple bilateral hypermetabolic nodules .\nIn light of the new pulmonary metastatic disease, additional systemic chemotherapy with carboplatin–paclitaxel was recommended to the patient. However, he opted for immunotherapy instead due to previous chemotherapy side effects and subsequently completed nine cycles of pembrolizumab. Imaging studies obtained after the third cycle of pembrolizumab demonstrated an interval decrease in the size of multiple pulmonary nodules bilaterally, suggesting a positive response to therapy . At the same time, however, a CT scan demonstrated an increase in the size of the thyroid mass . Additionally, new encasement of the distal common carotid artery, carotid bifurcation, and proximal internal carotid artery was present, and erosion of the thyroid cartilage was also identified. After the sixth cycle of pembrolizumab, imaging continued to demonstrate enlargement of the thyroid mass with increased extension to the tracheoesophageal groove, while the pulmonary nodules continued to get smaller . Following the ninth cycle of pembrolizumab, the thyroid mass had continued to enlarge, eroding the thyroid and cricoid cartilages, extending into the paraglottic space, and invading the cervical esophagus. No new or worsening pulmonary metastatic disease was identified at this time . The tenth cycle of pembrolizumab was halted due to leukocytosis (WBC 21.81 and ANC 19.05) and the patient’s desire to pursue supportive care. Fifteen months after his initial diagnosis, the patient was transitioned to comfort care and died 3 months later. Autopsy was not performed as the patient’s desire was to donate his body to science.", + "fulltext_subclaims": [ + "The patient was a 68-year-old White male.", + "He had T4aN1bM0, stage III (AJCC 8th edition) squamous cell carcinoma of the thyroid.", + "He had a history of prostate cancer treated with androgen deprivation therapy.", + "He had a history of external beam radiation therapy.", + "He had a history of brachytherapy.", + "He had a history of a benign parotid tumor status post-parotidectomy 20 years prior.", + "He took ranitidine 150 mg daily.", + "He took omeprazole 20 mg daily.", + "He took lisinopril 12.5 mg daily.", + "He took atorvastatin 20 mg daily.", + "He took montelukast 150 mg daily.", + "He took loratadine 10 mg daily.", + "He used naproxen and cannabis for cancer-related pain.", + "He first noticed a right neck mass while shaving 3 months prior to presentation.", + "He reported mild pain with swallowing.", + "He reported weight loss of unknown amount.", + "He reported right neck sensitivity to light touch.", + "He reported increased hoarseness.", + "He reported a raspy voice.", + "He was initially diagnosed with lymphadenopathy secondary to a sinus infection.", + "He received two rounds of antibiotics.", + "The mass failed to improve.", + "A fine needle aspiration of the lesion was performed.", + "Evaluation of the biopsy material demonstrated dysmorphic cells containing cytoplasmic keratin.", + "The cells stained positively for CK5/6.", + "The cells were consistent with squamous cell carcinoma.", + "Monoclonal PAX-8 staining was focally positive.", + "Subsequent laryngoscopy revealed no mucosal lesions.", + "Right vocal cord paralysis was observed.", + "A CT of the neck with contrast revealed a 4.8 cm peripherally enhancing hypodense mass with central necrosis lateral to the right hyoid bone.", + "The mass emanated from the thyroid gland.", + "Multiple smaller nodular lesions were identified in the prevertebral space.", + "Multiple smaller nodular lesions were identified in the right paraesophageal region.", + "Multiple smaller nodular lesions were identified in the superior mediastinum.", + "A staging PET scan showed a hypermetabolic right thyroid lobe.", + "The PET scan showed extensive conglomerate pathologic adenopathy at the right cervical lymph node chain.", + "The PET scan showed the lymph node chain extending inferior to the right thoracic inlet.", + "A left retropharyngeal hypermetabolic lymph node was identified.", + "No evidence of distant metastasis was found.", + "On physical examination, a large, firm, fixed right medial neck mass was noted.", + "The patient declined surgery.", + "The patient chose concurrent chemoradiation with weekly chemotherapy.", + "Intensity modulated radiation therapy (IMRT) was used to treat the right thyroid mass to 70 Gy in 35 fractions.", + "The radiation dose was 200 cGy per fraction.", + "The right thyroid mass was treated with IMRT.", + "Bilateral retropharyngeal nodes were treated to 63 Gy in 35 fractions.", + "The radiation dose for the retropharyngeal nodes was 180 cGy per fraction.", + "The patient completed radiation with weekly concurrent carboplatin-paclitaxel over 7 weeks.", + "During treatment, he developed grade 2 fatigue.", + "During treatment, he developed grade 2 mucositis.", + "During treatment, he developed grade 2 dermatitis.", + "During treatment, he developed grade 3 dysphagia.", + "During treatment, he developed grade 3 dry mouth with thickened secretions.", + "The skin desquamation was treated with silver sulfadiazine.", + "The skin desquamation was treated with mineral oil-hydrophil petrolat.", + "A percutaneous endoscopic gastrostomy (PEG) tube was placed during the first week of treatment.", + "The patient lost less than 15 lbs throughout the treatment.", + "Long-term toxicity was significant for chronic xerostomia.", + "Long-term toxicity was significant for chronic dysphagia.", + "A permanent gastrostomy tube was required.", + "The patient developed treatment-related hypothyroidism.", + "He was started on levothyroxine approximately 3 months after completion of treatment.", + "His TSH was 21 mIU/mL at that time.", + "The TSH was elevated.", + "After concurrent chemoradiation, the patient underwent two additional cycles of high-dose carboplatin–paclitaxel.", + "Follow-up imaging after concurrent chemoradiation suggested a partial therapeutic response.", + "PET/CT of the neck showed the thyroid mass decreased in size from 5.0 × 5.2 cm to 3.8 × 2.1 cm.", + "The maximum SUV of the thyroid mass decreased from 35.3 to 19.4.", + "The tumor was smaller, softer, and less tender to palpation.", + "The right and left neck lymph nodes were smaller.", + "The right and left neck lymph nodes demonstrated less PET-avidity.", + "Imaging of the chest revealed pulmonary metastases up to 9 mm in size.", + "Multiple bilateral hypermetabolic nodules were identified.", + "Additional systemic chemotherapy with carboplatin–paclitaxel was recommended.", + "The patient opted for immunotherapy instead.", + "He completed nine cycles of pembrolizumab.", + "Imaging after the third cycle showed an interval decrease in the size of multiple pulmonary nodules.", + "This suggested a positive response to therapy.", + "A CT scan after the third cycle showed an increase in the size of the thyroid mass.", + "New encasement of the distal common carotid artery was present.", + "New encasement of the carotid bifurcation was present.", + "New encasement of the proximal internal carotid artery was present.", + "Erosion of the thyroid cartilage was identified.", + "After the sixth cycle, imaging showed enlargement of the thyroid mass.", + "The thyroid mass extended to the tracheoesophageal groove.", + "The pulmonary nodules continued to get smaller.", + "After the ninth cycle, the thyroid mass continued to enlarge.", + "The thyroid mass eroded the thyroid and cricoid cartilages.", + "The thyroid mass extended into the paraglottic space.", + "The thyroid mass invaded the cervical esophagus.", + "No new or worsening pulmonary metastatic disease was identified.", + "The tenth cycle of pembrolizumab was halted due to leukocytosis.", + "The patient’s white blood cell count was 21.81.", + "The patient’s absolute neutrophil count was 19.05.", + "The patient’s desire was to pursue supportive care.", + "The patient was transitioned to comfort care 15 months after initial diagnosis.", + "The patient died 3 months after being transitioned to comfort care.", + "Autopsy was not performed.", + "The patient’s desire was to donate his body to science." + ], + "summary": "We report a rare case of primary squamous cell carcinoma of the thyroid in a 68-year-old White male who underwent chemoradiation and palliative immunotherapy after declining surgery. He was treated with intensity-modulated radiation therapy to 70 Gy in 35 fractions, with concurrent carboplatin-paclitaxel and palliative pembrolizumab. Local thyroid disease recurrence occurred at 6 months post-chemoradiation, and the patient died at 16 months post-chemoradiation.", + "summary_subclaims": [ + "The patient is a 68-year-old White male.", + "The patient had primary squamous cell carcinoma of the thyroid.", + "The patient declined surgery.", + "The patient underwent chemoradiation.", + "The patient received intensity-modulated radiation therapy to 70 Gy in 35 fractions.", + "The patient received concurrent carboplatin-paclitaxel.", + "The patient received palliative pembrolizumab.", + "Local thyroid disease recurrence occurred at 6 months post-chemoradiation.", + "The patient died at 16 months post-chemoradiation." + ] + }, + { + "id": "multiclinsum_test_2595_en.txt", + "fulltext": "A 48-year-old Chinese woman was administered a blood-activating and stasis-eliminating compound by a local physician for ankle pain. A “blood-activating and stasis-eliminating compound” is a type of traditional medicine that can be used as an analgesic and antipyretic. The ingredients of this blood-activating and stasis-eliminating compound include safflower, dog ridge (made), mistletoe, herba lycopi leaf, spatholobi, caulis trachelospermi, cocklebur, Cyperus rotundus, Periploca sepium Bge, and natural copper (calcined). It does not cause an autoimmune response, such as rash or vasculitis. Edema and skin rashes in both lower limbs appeared 3 days after this treatment. She was further treated for edema with furosemide and spironolactone at the same local hospital, and she was transferred to our hospital in September 2019. She did not have diabetes, nor did she have any relevant family, life, or allergy history. At admission, her vital signs on physical examination were as follows: body temperature, 36.5 °C; blood pressure, 127/90 mmHg; pulse, 71 beats/min; and respiratory rate, 20 breaths/min. Several round areas of the skin rash of varying sizes were seen on the arms, legs, and trunk. Pitting edema was observed in both lower limbs. Abdominal and cardiac exams showed no abnormalities.\nThe laboratory test results were as follows: urinary protein, 2+; blood protein, 3+; urinary protein excretion, 5.02 g/24 h; and creatinine, 385 μmol/L . Further assessment revealed that the patient was positive for ANCAs by indirect immunofluorescence (a titer of 1:10), positive for p-ANCAs (a titer of 3.1 as the antibody index) by enzyme-linked immunosorbent assay (ELISA), and negative for both anti-GBM and anti-proteinase 3 (c-ANCA) antibodies after three repeated assays . Computerized tomography (CT) revealed scattered areas of inflammation in both lungs, with a small amount of pericardial effusion and bilateral pleural effusion. Half a month later, CT showed no inflammation in either lung, and the pleural effusion had disappeared . Renal ultrasonography showed normal-sized kidneys with elevated echogenicity.\nLight microscopy on a Nikon ECLIPSE E-200 microscope (Nikon, Tokyo, Japan) revealed a total of 13 glomeruli, with three globally sclerotic glomeruli. Ten glomeruli had cellular crescents, and three had fibrocellular crescents, which suggested crescentic glomerulonephritis. The obliteration of Bowman’s capsules and segmental sclerotic lesions were noted in 5 glomeruli. In addition, tubular atrophy (30%) was accompanied by interstitial fibrosis (30%), with the interstitial infiltration of lymphocytes, monocytes, and plasmocytes . Immunofluorescence was observed under Olympus BX41microscope (Olympus, Tokyo, Japan) to assess five glomeruli, which showed IgG linearly deposited alongside the GBM . Electron microscopy (EM) performed with a transmission electron microscope (JEOL Ltd., Tokyo, Japan) showed the collapse and rupture of the GBM in the presence of foot process fusion. The absence of electron-dense deposits was another EM hallmark of the disease . Therefore, a diagnosis of anti-GBM disease with positivity for p-ANCA and another atypical ANCA was established, despite repeated negative serum anti-GBM antibody test results.\nAfter the diagnosis of anti-GBM disease was established based on the clinical features and biopsy findings in our patient, treatment with methylprednisolone and plasmapheresis was initiated immediately. The treatment was initiated with 500 mg of intravenous high-dose methylprednisolone, which was administered three times, followed by oral prednisone at 50 mg per day. A hemodialysis catheter was implanted in the right femoral vein to enable plasmapheresis every 2 days (ten sessions in all). Interestingly, positivity for p-ANCA disappeared, but the patient was still positive for total ANCAs after the fourth session of plasmapheresis; the patient was negative for both c-ANCA and anti-GBM antibodies at admission. However, no signals for total ANCA or anti-GBM antibodies were observed after ten sessions of plasmapheresis.\nThe patient had good tolerance of all drugs and procedures and was successfully discharged after medical care. She was followed up via outpatient visits to continue treatment with prednisolone and cyclophosphamide. Additionally, her kidney function and lung disease were regularly monitored in specialized departments.", + "fulltext_subclaims": [ + "A 48-year-old Chinese woman was administered a blood-activating and stasis-eliminating compound by a local physician for ankle pain.", + "A 'blood-activating and stasis-eliminating compound' is a type of traditional medicine that can be used as an analgesic and antipyretic.", + "The ingredients of this blood-activating and stasis-eliminating compound include safflower, dog ridge (made), mistletoe, herba lycopi leaf, spatholobi, caulis trachelospermi, cocklebur, Cyperus rotundus, Periploca sepium Bge, and natural copper (calcined).", + "It does not cause an autoimmune response, such as rash or vasculitis.", + "Edema and skin rashes in both lower limbs appeared 3 days after this treatment.", + "She was further treated for edema with furosemide and spironolactone at the same local hospital.", + "She was transferred to our hospital in September 2019.", + "She did not have diabetes.", + "She did not have any relevant family, life, or allergy history.", + "At admission, her body temperature was 36.5 °C.", + "At admission, her blood pressure was 127/90 mmHg.", + "At admission, her pulse was 71 beats/min.", + "At admission, her respiratory rate was 20 breaths/min.", + "Several round areas of the skin rash of varying sizes were seen on the arms, legs, and trunk.", + "Pitting edema was observed in both lower limbs.", + "Abdominal and cardiac exams showed no abnormalities.", + "Urinary protein was 2+.", + "Blood protein was 3+.", + "Urinary protein excretion was 5.02 g/24 h.", + "Creatinine was 385 μmol/L.", + "The patient was positive for ANCAs by indirect immunofluorescence (a titer of 1:10).", + "The patient was positive for p-ANCAs (a titer of 3.1 as the antibody index) by enzyme-linked immunosorbent assay (ELISA).", + "The patient was negative for both anti-GBM and anti-proteinase 3 (c-ANCA) antibodies after three repeated assays.", + "Computerized tomography (CT) revealed scattered areas of inflammation in both lungs.", + "CT showed a small amount of pericardial effusion.", + "CT showed bilateral pleural effusion.", + "Half a month later, CT showed no inflammation in either lung.", + "The pleural effusion had disappeared.", + "Renal ultrasonography showed normal-sized kidneys with elevated echogenicity.", + "Light microscopy revealed a total of 13 glomeruli.", + "Three glomeruli were globally sclerotic.", + "Ten glomeruli had cellular crescents.", + "Three glomeruli had fibrocellular crescents.", + "This suggested crescentic glomerulonephritis.", + "Obliteration of Bowman’s capsules and segmental sclerotic lesions were noted in 5 glomeruli.", + "Tubular atrophy (30%) was accompanied by interstitial fibrosis (30%).", + "The interstitial infiltration of lymphocytes, monocytes, and plasmocytes was observed.", + "Immunofluorescence showed IgG linearly deposited alongside the GBM.", + "Electron microscopy showed the collapse and rupture of the GBM in the presence of foot process fusion.", + "The absence of electron-dense deposits was another EM hallmark of the disease.", + "A diagnosis of anti-GBM disease with positivity for p-ANCA and another atypical ANCA was established.", + "The patient was negative for both c-ANCA and anti-GBM antibodies at admission.", + "Treatment with methylprednisolone and plasmapheresis was initiated immediately.", + "The treatment was initiated with 500 mg of intravenous high-dose methylprednisolone, which was administered three times.", + "Oral prednisone at 50 mg per day was continued.", + "A hemodialysis catheter was implanted in the right femoral vein to enable plasmapheresis every 2 days.", + "Ten sessions of plasmapheresis were performed.", + "Positivity for p-ANCA disappeared after the fourth session of plasmapheresis.", + "The patient was still positive for total ANCAs after the fourth session of plasmapheresis.", + "No signals for total ANCA or anti-GBM antibodies were observed after ten sessions of plasmapheresis.", + "The patient had good tolerance of all drugs and procedures.", + "She was successfully discharged after medical care.", + "She was followed up via outpatient visits to continue treatment with prednisolone and cyclophosphamide.", + "Her kidney function and lung disease were regularly monitored in specialized departments." + ], + "summary": "We herein report the rare case of a patient with atypical anti-GBM disease whose serum was negative for the anti-GBM antibody but positive for the myeloperoxidase (MPO) anti-neutrophil cytoplasmic antibody (p-ANCA) and another atypical ANCA. Laboratory test results showed severe renal insufficiency with a creatinine level of 385 μmol/L. Renal biopsy specimen analysis revealed 100% glomeruli with crescents; immunofluorescence showed immunoglobulin G (IgG) linearly deposited alongside the GBM. Finally, the patient was discharged successfully after treatment with plasmapheresis, methylprednisolone and prednisone.", + "summary_subclaims": [ + "The patient had atypical anti-GBM disease.", + "The patient's serum was negative for the anti-GBM antibody.", + "The patient's serum was positive for the myeloperoxidase (MPO) anti-neutrophil cytoplasmic antibody (p-ANCA).", + "The patient's serum was positive for another atypical ANCA.", + "Laboratory test results showed a creatinine level of 385 μmol/L.", + "Renal biopsy specimen analysis revealed 100% glomeruli with crescents.", + "Immunofluorescence showed immunoglobulin G (IgG) linearly deposited alongside the GBM.", + "The patient was treated with plasmapheresis, methylprednisolone, and prednisone.", + "The patient was discharged successfully after treatment." + ] + }, + { + "id": "multiclinsum_test_2794_en.txt", + "fulltext": "A 57-year-old Caucasian woman presented with a large non-tender submandibular mass. The lesion had been present for about 25 years with a slow increase in size. Our patient's medical history was unremarkable. A physical examination revealed a giant painless, movable, semi-hard elastic mass in her right submandibular region measuring about 8×6 cm. Fine needle aspiration cytology was suggestive of a PA. Contrast-enhancement computerized tomography confirmed a giant well-defined mass without cystic changes in her right submandibular region . No lymph node swelling or other tumorous lesions were detected. Submandibular tumor extirpation was performed under general anesthesia.\nImmediately after removal, samples were obtained in the surgery room following a topographic scheme . Group 1 comprised six samples from the periphery of the tumor, adjacent to the subcutaneous tissue; group 2 comprised six samples from the periphery of the tumor, adjacent to the floor of the mouth; and for group 3, the tumor was opened along the midline, and six deep samples were extracted from the center of the tumor.\nHalf of the samples in each group were fixed in 4% buffered formalin, processed and embedded in paraffin according to routine procedures, for histological and immunohistochemical analysis. The remainder of the samples of fresh material for each group were immediately submitted for DNA flow cytometry. The rest of the surgical specimen was routinely studied in the Department of Pathology and diagnosed as a benign PA.\nSamples of each group were minced with a scalpel in phosphate-buffered saline solution. Single nuclear suspensions were prepared by filtering through a 50-μm nylon mesh. The DNA contents were measured in a Cytomics FC500 (Beckman Coulter Inc., Fullerton, CA, USA) flow cytometer. DNA histograms of at least 10, 000 nuclei were plotted. The DNA-diploid cell population corresponding to surrounding normal tissue from the same location was used as an internal reference standard for the identification of DNA-aneuploid clones. The percentages of the cell cycle phases as well as the DNA indices of the aneuploid clones were calculated using the Modfit 5.2 software package. DNA histograms were classified as diploid if there was a single G0-G1 peak and aneuploid if additional G0-G1 peaks were present. The ratio of aneuploid G0-G1 peak values to diploid G0-G1 peak values was expressed as a DNA index. All specimens had a G0-G1 peak coefficient of variation of no more than 4%. The following were taken as cytometric variables: DNA ploidy, DNA index, and S-phase fraction. The cases with DNA indices between 0.9 and 1.10 were considered as DNA diploids, and those less than 0.9 or greater than 1.10 as DNA aneuploids.\nHalf of the paraffin-embedded samples of all three groups were routinely stained with hematoxylin and eosin. The rest of the paraffin samples were submitted to the labeled-polymer method of immunohistochemistry using antibodies against α-smooth-muscle actin (α-SMA), cytokeratin (CK) AE1/AE3, CK 8, protein 53 (p53), protein 63 (p63) and antigen Ki67.\nThe histogram of Group 1 samples presented a single peak in the G0-G1 area. The cell nuclei population was 5.91% in the G2 region and 91.30% in the G1 area. The proportion of cells in the S-phase was 2.78% and the coefficient of variance (CV) was 3.70%. Samples of this group were considered as being DNA diploid . Group 2 samples also exhibited a DNA diploid pattern with an 88.26% nuclei population in the G1 region and 8.80% in the G2 area. The S-phase fraction was 2.95% and the CV was 3.04% . Group 3 samples showed DNA aneuploidy: 48.70% of the cell population was considered diploid with 4.18% in the G2 region, 91.27% in the G1 area and a CV of 2.17%, whereas 51.30% of the cells analyzed presented an aneuploid pattern with 10.53% in the G2 region, 89.03% in the G1 area and a CV of 7.08%. The total aneuploid S-phase was 0.44% and the total S-phase fraction was 2.45% .\nHistological analysis of Group 1 and Group 2 samples showed ductal structures, cords and islands of polygonal cells without atypia, sheets and strands of hyaline or plasmacytoid cells in a myxoid stroma. These findings were consistent with PA . On immunohistochemistry, slight positivity was observed in the ductal cells with CK AE1/AE3 and CK 8 . The non-luminal cells strongly expressed α-SMA . Occasional cells were positive with proliferation antigen Ki67 and no expression was observed with p53 . Otherwise, myoepithelial cells showed high positive nuclear staining for p63 .\nGroup 3 samples exhibited an unusual histological pattern. These hypercellular areas were composed of blocks of round to ovoid epithelial cells without the 'reminiscent' myoepithelium. The epithelial cells were round with pale eosinophilic cytoplasm and round to oval nuclei. Nuclear pleomorphism or atypia, malignant luminal cells and necrotic foci were not observed . The immunohistochemical study showed strong expression of CKs AE1/AE3 and CK 8 in most of the epithelial cells . p63 and α-SMA staining were seen to a lesser degree than in the Group 1 and 2 samples whereas expression of antigen Ki67 was more intense . p53 was expressed in a few epithelial cells .", + "fulltext_subclaims": [ + "The patient was a 57-year-old Caucasian woman.", + "She presented with a large non-tender submandibular mass.", + "The lesion had been present for about 25 years.", + "The lesion had a slow increase in size.", + "The patient's medical history was unremarkable.", + "A physical examination revealed a giant painless, movable, semi-hard elastic mass in her right submandibular region.", + "The mass measured about 8×6 cm.", + "Fine needle aspiration cytology was suggestive of a PA.", + "Contrast-enhancement computerized tomography confirmed a giant well-defined mass without cystic changes in her right submandibular region.", + "No lymph node swelling was detected.", + "No other tumorous lesions were detected.", + "Submandibular tumor extirpation was performed under general anesthesia.", + "Immediately after removal, samples were obtained in the surgery room following a topographic scheme.", + "Group 1 comprised six samples from the periphery of the tumor, adjacent to the subcutaneous tissue.", + "Group 2 comprised six samples from the periphery of the tumor, adjacent to the floor of the mouth.", + "Group 3 samples were extracted from the center of the tumor.", + "Half of the samples in each group were fixed in 4% buffered formalin.", + "The remainder of the samples of fresh material for each group were immediately submitted for DNA flow cytometry.", + "The rest of the surgical specimen was diagnosed as a benign PA.", + "The DNA contents were measured in a Cytomics FC500 flow cytometer.", + "DNA histograms of at least 10,000 nuclei were plotted.", + "The DNA-diploid cell population corresponding to surrounding normal tissue from the same location was used as an internal reference standard.", + "The percentages of the cell cycle phases as well as the DNA indices of the aneuploid clones were calculated using the Modfit 5.2 software package.", + "DNA histograms were classified as diploid if there was a single G0-G1 peak.", + "DNA histograms were classified as aneuploid if additional G0-G1 peaks were present.", + "The ratio of aneuploid G0-G1 peak values to diploid G0-G1 peak values was expressed as a DNA index.", + "All specimens had a G0-G1 peak coefficient of variation of no more than 4%.", + "The following were taken as cytometric variables: DNA ploidy, DNA index, and S-phase fraction.", + "Cases with DNA indices between 0.9 and 1.10 were considered as DNA diploids.", + "Cases with DNA indices less than 0.9 or greater than 1.10 were considered as DNA aneuploids.", + "Half of the paraffin-embedded samples of all three groups were routinely stained with hematoxylin and eosin.", + "The rest of the paraffin samples were submitted to the labeled-polymer method of immunohistochemistry.", + "The histogram of Group 1 samples presented a single peak in the G0-G1 area.", + "The cell nuclei population was 5.91% in the G2 region and 91.30% in the G1 area.", + "The proportion of cells in the S-phase was 2.78%.", + "The coefficient of variance for Group 1 samples was 3.70%.", + "Group 1 samples were considered as being DNA diploid.", + "Group 2 samples also exhibited a DNA diploid pattern.", + "Group 2 samples had an 88.26% nuclei population in the G1 region.", + "Group 2 samples had 8.80% in the G2 area.", + "The S-phase fraction for Group 2 samples was 2.95%.", + "The coefficient of variance for Group 2 samples was 3.04%.", + "Group 3 samples showed DNA aneuploidy.", + "Group 3 samples had 48.70% of the cell population considered diploid.", + "Group 3 samples had 4.18% in the G2 region.", + "Group 3 samples had 91.27% in the G1 area.", + "The coefficient of variance for the diploid portion of Group 3 samples was 2.17%.", + "Group 3 samples had 51.30% of the cells analyzed presenting an aneuploid pattern.", + "The aneuploid portion of Group 3 samples had 10.53% in the G2 region.", + "The aneuploid portion of Group 3 samples had 89.03% in the G1 area.", + "The coefficient of variance for the aneuploid portion of Group 3 samples was 7.08%.", + "The total aneuploid S-phase for Group 3 samples was 0.44%.", + "The total S-phase fraction for Group 3 samples was 2.45%.", + "Histological analysis of Group 1 and Group 2 samples showed ductal structures.", + "Histological analysis of Group 1 and Group 2 samples showed cords and islands of polygonal cells without atypia.", + "Histological analysis of Group 1 and Group 2 samples showed sheets and strands of hyaline or plasmacytoid cells in a myxoid stroma.", + "These findings were consistent with PA.", + "On immunohistochemistry, slight positivity was observed in the ductal cells with CK AE1/AE3 and CK 8.", + "The non-luminal cells strongly expressed α-SMA.", + "Occasional cells were positive with proliferation antigen Ki67.", + "No expression was observed with p53.", + "Myoepithelial cells showed high positive nuclear staining for p63.", + "Group 3 samples exhibited an unusual histological pattern.", + "These hypercellular areas were composed of blocks of round to ovoid epithelial cells without the 'reminiscent' myoepithelium.", + "The epithelial cells were round with pale eosinophilic cytoplasm and round to oval nuclei.", + "Nuclear pleomorphism or atypia was not observed.", + "Malignant luminal cells were not observed.", + "Necrotic foci were not observed.", + "The immunohistochemical study showed strong expression of CKs AE1/AE3 and CK 8 in most of the epithelial cells.", + "p63 and α-SMA staining were seen to a lesser degree than in the Group 1 and 2 samples.", + "Expression of antigen Ki67 was more intense.", + "p53 was expressed in a few epithelial cells." + ], + "summary": "We extensively analyze a giant submandibular mixed tumor of 25-year evolution in a 57-year-old Caucasian woman. Deoxyribonucleic acid ploidy was evaluated in different superficial and deep areas using flow cytometry analysis and correlated with pathological and immunohistochemical characteristics. Superficial areas exhibited a typical histological pleomorphic adenoma pattern and were deoxyribonucleic acid diploid. Deep samples showed deoxyribonucleic acid aneuploidy, atypical histological benign features and expression of markers involved at an early-stage of malignant transformation, such as tumor protein 53 and antigen Ki67.", + "summary_subclaims": [ + "The patient is a 57-year-old Caucasian woman.", + "The submandibular mixed tumor had a 25-year evolution.", + "DNA ploidy was evaluated in different superficial and deep areas.", + "Flow cytometry analysis was used.", + "Superficial areas exhibited a typical histological pleomorphic adenoma pattern.", + "Superficial areas were DNA diploid.", + "Deep samples showed DNA aneuploidy.", + "Deep samples showed atypical histological benign features.", + "Deep samples showed expression of tumor protein 53.", + "Deep samples showed expression of antigen Ki67." + ] + }, + { + "id": "multiclinsum_test_1093_en.txt", + "fulltext": "A 53-year-old Canadian Caucasian woman, who was a clerical worker, presented to her family doctor with a five week history of progressive pain and black discoloration of the distal right third finger. She was initiated on acetylsalicylic acid and warfarin and referred to a regional tertiary care hospital.\nHer past medical history included depression and a diagnosis of Wolfe Parkinson White (WPW) syndrome, treated since childhood with verapamil. She was taking no other medications. She has never smoked and denied a history of Raynaud's type changes in her digits. Her connective tissue disease review of systems was also otherwise unremarkable.\nOn examination in the emergency room, there was obvious digital necrosis of the distal right third finger with an adjacent area of pale swollen tissue with ulceration . Allen's test was abnormal with poor refill bilaterally. Capillaroscopic examination of the periungal regions did not reveal dilated capillary loops. No peripheral bruits were audible. A teleangiectasia lesion was evident on the fifth digit. No other skin changes, specifically sclerodactyly, were present. She was admitted to hospital for further investigations and consultation with vascular specialists.\nAn angiogram revealed evidence of a bilateral obliterative vasculopathic process . Radiographs of the hands did not reveal any bony abnormality. Further investigations revealed a positive antinuclear antibody with titer > 1280 and anticentromere specificity. ACA were confirmed by enzyme-linked immunosorbent assay (ELISA) at greater than 100 U/mL. Anti-double stranded DNA, anti-Sjogrens Syndrome A, anti-Sjogrens Syndrome B and anti-ribonucleoprotein antibodies (anti-SSA, anti-SSB, anti-RNP), anti-Sm, anti-Scl-70, antineutrophil cytoplasmic antibodies, anticardiolipin antibodies, cryoglobulins, C3, C4, C-reactive protein, complete blood count, electrolytes, creatinine, hepatic transaminases, alkaline phosphatase and urinalysis were all normal or negative. Associated underlying pathology including cardiopulmonary, gastrointestinal and renal involvement were excluded through cardiology consultation, chest radiograph, echocardiogram, pulmonary function testing, high-resolution computerized tomography (CT) of the chest, 24 hour urine for creatinine clearance, serum chemistry and urinalysis, barium swallow, and CT abdomen and pelvis.\nIn hospital she was initiated on clopidogrel bisulfate, pentoxifylline, topical nitropaste, a two week trial of prednisone, a seven day course of clindamycin and morphine for pain control. Nifedipine was later initiated as an out-patient. Gradually over the next two months the necrosis resolved with minimal tissue loss at the digit tip. She continues to be followed in the rheumatology out-patient clinic with periodic evaluations for potential evolution of connective tissue disease and in cardiology clinic for follow-up of her WPW.", + "fulltext_subclaims": [ + "The patient is a 53-year-old Canadian Caucasian woman.", + "She was a clerical worker.", + "She presented with a five week history of progressive pain and black discoloration of the distal right third finger.", + "She was initiated on acetylsalicylic acid and warfarin.", + "She was referred to a regional tertiary care hospital.", + "Her past medical history included depression.", + "She had a diagnosis of Wolfe Parkinson White (WPW) syndrome.", + "She was treated since childhood with verapamil.", + "She was taking no other medications.", + "She has never smoked.", + "She denied a history of Raynaud's type changes in her digits.", + "On examination in the emergency room, there was obvious digital necrosis of the distal right third finger.", + "Allen's test was abnormal with poor refill bilaterally.", + "Capillaroscopic examination of the periungal regions did not reveal dilated capillary loops.", + "A teleangiectasia lesion was evident on the fifth digit.", + "An angiogram revealed evidence of a bilateral obliterative vasculopathic process.", + "Radiographs of the hands did not reveal any bony abnormality.", + "Further investigations revealed a positive antinuclear antibody with titer > 1280 and anticentromere specificity.", + "ACA were confirmed by enzyme-linked immunosorbent assay (ELISA) at greater than 100 U/mL.", + "Anti-double stranded DNA, anti-Sjogrens Syndrome A, anti-Sjogrens Syndrome B and anti-ribonucleoprotein antibodies (anti-SSA, anti-SSB, anti-RNP), anti-Sm, anti-Scl-70, antineutrophil cytoplasmic antibodies, anticardiolipin antibodies, cryoglobulins, C3, C4, C-reactive protein, complete blood count, electrolytes, creatinine, hepatic transaminases, alkaline phosphatase and urinalysis were all normal or negative.", + "In hospital she was initiated on clopidogrel bisulfate.", + "In hospital she was initiated on pentoxifylline.", + "In hospital she was initiated on topical nitropaste.", + "In hospital she was started on a two week trial of prednisone.", + "In hospital she was started on a seven day course of clindamycin.", + "In hospital she was started on morphine for pain control.", + "Nifedipine was later initiated as an out-patient.", + "Gradually over the next two months the necrosis resolved with minimal tissue loss at the digit tip.", + "She continues to be followed in the rheumatology out-patient clinic.", + "She continues to be followed in cardiology clinic for follow-up of her WPW." + ], + "summary": "Our patient, a 53-year-old Caucasian woman, non-smoker, presented with progressive pain and blackening of the distal right third finger over the preceding five weeks. No sclerodactyly was evident. She was anticentromere antibody positive at greater than 100 U/mL. Angiography revealed diffuse distal vasculopathy in both upper extremities. Other investigations were unremarkable.", + "summary_subclaims": [ + "The patient is a 53-year-old Caucasian woman.", + "The patient is a non-smoker.", + "The patient had progressive pain and blackening of the distal right third finger over the preceding five weeks.", + "No sclerodactyly was evident.", + "The patient was anticentromere antibody positive at greater than 100 U/mL.", + "Angiography revealed diffuse distal vasculopathy in both upper extremities.", + "Other investigations were unremarkable." + ] + }, + { + "id": "multiclinsum_test_1899_en.txt", + "fulltext": "A 31-year-old previously healthy Sri Lankan woman from southern parts of Sri Lanka presented with fever for 3 days and altered level of consciousness for 1 day. The fever was associated with headache and myalgia and she did not have nausea, vomiting, or skin rashes. On admission to our hospital she was afebrile and nuchal rigidity was present. She was conscious but aphasic. Her Glasgow Coma Scale was 11/15 (E 4, V 1, M 6). There were involuntary conjugate fast eye movements in all the directions of gaze without a saccadic interval, suggestive of opsoclonus. There were no ophthalmoplegia or other cranial nerve palsies. Her pupils were equally reacting to light. Fundoscopy revealed papilledema. There were involuntary twitching movements on the right side of her face, mandible, and tongue, which increased with movement and disappeared during sleep. Both upper and lower limb tone were normal and she was able to move her limbs against gravity, but not against resistance (power 3/5). The deep tendon reflexes were present. Bilateral plantar responses were flexor. Her other vital signs were stable with a heart rate of 68 beats per minute (bpm), blood pressure of 130/80 mmHg, and blood oxygen saturation (spO2) on air was 96%. All other system examinations were unremarkable.\nHer full blood count revealed a neutrophil leukocytosis: white blood cells, 14 × 103/μL; neutrophills (N), 78%; lymphocytes (L), 11%; eosinophills (E), 02%; basophills (B), 5%; platelets, 280 × 103/μL; and hemoglobin, 13 g/dl. Her erythrocyte sedimentation rate was 66 mm in the first hour but her C-reactive protein was less than 6 mg/dl. Her serum electrolytes and renal and liver profiles were normal: sodium (Na), 133 mmol/l; potassium (K), 4.5 mmol/l; serum calcium, 2.3 mmol/l; magnesium, 0.99 mmol/l; aspartate aminotransferase (AST), 40 U/l; and alanine aminotransferase (ALT), 47 U/l. Her thyroid stimulating hormone was 0.34 IU/L. Blood and urine culture, blood film for malaria parasite, rheumatoid factor, antinuclear antibody, and human immunodeficiency virus serology were negative. Thyroid microsomal antibody was less than 10 IU/ml and N-methyl-D-aspartate (NMDA) receptor antibody was also negative. A non-contrast computed tomography of her brain showed cerebral edema. Cerebrospinal fluid (CSF) opening pressure was 180 mmH2O and full report showed high level of proteins of 130 mg/dl with 60 lymphocytes/mm3. Polymorphs and red blood cells were absent in CSF. CSF glucose was 3.4 mmol/l (corresponding random blood sugar was 5.5 mmol/l). Herpes simplex virus polymerase chain reaction in CSF was negative. IgM for JE became positive in both serum and CSF. Magnetic resonance imaging (MRI) of her brain showed symmetrical bilateral high signal intensities in basal ganglia, head of the caudate, and midbrain in T2 and fluid-attenuated inversion recovery (FLAIR) without diffusion restriction . Serial electroencephalograms (EEGs) were done which showed various epileptiform discharges. Initial EEG showed bilateral periodic lateralized epileptiform discharges and the second EEG after 2 days showed left-sided lateralization with background slowing.\nShe was given supportive care and once JE was confirmed we administered methylprednisolone pulses intravenously (1000 mg per day) for 5 days. With this, she improved gradually with reduction in opsoclonus and myoclonic movements. Her limb muscle power and speech also improved slowly. After approximately 2 weeks of the disease duration, epileptic discharges and background slowing in an EEG showed improvement. During the course of her illness she became rigid and a quarter of a tablet of levodopa-carbidopa (250/25 mg) was started at a frequency of three times a day to alleviate the extrapyramidal symptoms.", + "fulltext_subclaims": [ + "The patient is a 31-year-old previously healthy Sri Lankan woman from southern parts of Sri Lanka.", + "She presented with fever for 3 days and altered level of consciousness for 1 day.", + "The fever was associated with headache and myalgia.", + "She did not have nausea, vomiting, or skin rashes.", + "On admission, she was afebrile.", + "Nuchal rigidity was present.", + "She was conscious but aphasic.", + "Her Glasgow Coma Scale was 11/15 (E 4, V 1, M 6).", + "There were involuntary conjugate fast eye movements in all the directions of gaze without a saccadic interval, suggestive of opsoclonus.", + "There were no ophthalmoplegia or other cranial nerve palsies.", + "Her pupils were equally reacting to light.", + "Fundoscopy revealed papilledema.", + "There were involuntary twitching movements on the right side of her face, mandible, and tongue, which increased with movement and disappeared during sleep.", + "Both upper and lower limb tone were normal.", + "She was able to move her limbs against gravity, but not against resistance (power 3/5).", + "The deep tendon reflexes were present.", + "Bilateral plantar responses were flexor.", + "Her heart rate was 68 beats per minute.", + "Her blood pressure was 130/80 mmHg.", + "Her blood oxygen saturation on air was 96%.", + "Her white blood cells were 14 × 103/μL.", + "Her neutrophils were 78%.", + "Her lymphocytes were 11%.", + "Her eosinophils were 2%.", + "Her basophils were 5%.", + "Her platelets were 280 × 103/μL.", + "Her hemoglobin was 13 g/dl.", + "Her erythrocyte sedimentation rate was 66 mm in the first hour.", + "Her C-reactive protein was less than 6 mg/dl.", + "Her serum electrolytes and renal and liver profiles were normal.", + "Her sodium was 133 mmol/l.", + "Her potassium was 4.5 mmol/l.", + "Her serum calcium was 2.3 mmol/l.", + "Her magnesium was 0.99 mmol/l.", + "Her aspartate aminotransferase was 40 U/l.", + "Her alanine aminotransferase was 47 U/l.", + "Her thyroid stimulating hormone was 0.34 IU/L.", + "Blood and urine culture were negative.", + "Blood film for malaria parasite was negative.", + "Rheumatoid factor was negative.", + "Antinuclear antibody was negative.", + "Human immunodeficiency virus serology was negative.", + "Thyroid microsomal antibody was less than 10 IU/ml.", + "N-methyl-D-aspartate (NMDA) receptor antibody was also negative.", + "A non-contrast computed tomography of her brain showed cerebral edema.", + "Cerebrospinal fluid opening pressure was 180 mmH2O.", + "Cerebrospinal fluid showed high level of proteins of 130 mg/dl.", + "Cerebrospinal fluid showed 60 lymphocytes/mm3.", + "Polymorphs and red blood cells were absent in cerebrospinal fluid.", + "Cerebrospinal fluid glucose was 3.4 mmol/l.", + "Herpes simplex virus polymerase chain reaction in cerebrospinal fluid was negative.", + "IgM for JE became positive in both serum and cerebrospinal fluid.", + "Magnetic resonance imaging of her brain showed symmetrical bilateral high signal intensities in basal ganglia, head of the caudate, and midbrain in T2 and fluid-attenuated inversion recovery without diffusion restriction.", + "Serial electroencephalograms were done.", + "Initial electroencephalogram showed bilateral periodic lateralized epileptiform discharges.", + "The second electroencephalogram after 2 days showed left-sided lateralization with background slowing.", + "She was given supportive care.", + "Once JE was confirmed, she was administered methylprednisolone pulses intravenously (1000 mg per day) for 5 days.", + "With this, she improved gradually with reduction in opsoclonus and myoclonic movements.", + "Her limb muscle power and speech also improved slowly.", + "After approximately 2 weeks of the disease duration, epileptic discharges and background slowing in an electroencephalogram showed improvement.", + "During the course of her illness, she became rigid.", + "A quarter of a tablet of levodopa-carbidopa (250/25 mg) was started at a frequency of three times a day to alleviate the extrapyramidal symptoms." + ], + "summary": "Here we present the case of a 31-year-old Sri Lankan woman who presented with fever, altered level of consciousness, opsoclonus, and facial myoclonus. She was diagnosed as having Japanese encephalitis based on cerebrospinal fluid and serum Japanese encephalitis-specific immunoglobulin M antibody and characteristic magnetic resonance imaging abnormalities. She was given intravenously administered methylprednisolone pulses (1000 mg per day) for 5 days. With this she improved gradually with reduction in opsoclonus and myoclonic movements. Her limb muscle power and speech also improved slowly.", + "summary_subclaims": [ + "The patient was a 31-year-old Sri Lankan woman.", + "She presented with fever.", + "She had an altered level of consciousness.", + "She had opsoclonus.", + "She had facial myoclonus.", + "She was diagnosed as having Japanese encephalitis.", + "The diagnosis was based on cerebrospinal fluid and serum Japanese encephalitis-specific immunoglobulin M antibody.", + "The diagnosis was based on characteristic magnetic resonance imaging abnormalities.", + "She was given intravenously administered methylprednisolone pulses.", + "The methylprednisolone dose was 1000 mg per day.", + "The methylprednisolone was given for 5 days.", + "With this treatment, she improved gradually.", + "There was a reduction in opsoclonus.", + "There was a reduction in myoclonic movements.", + "Her limb muscle power improved slowly.", + "Her speech improved slowly." + ] + }, + { + "id": "multiclinsum_test_1411_en.txt", + "fulltext": "A 48-year-old Thai woman with congenital mutism presented with a 3-month history of intermittent swelling of both lower limbs. She was otherwise well and did not report joint pain, headache, photophobia, rash, dyspnea, orthopnea, palpitations, hair loss, or bowel symptoms. Her appetite was normal. She had no history of clinically significant underlying diseases; she was not receiving any drug treatments; and she did not drink alcohol or smoke. Her physical examination revealed that she was well; her weight was 41 kg, and her body temperature was 37.2 °C, pulse rate was 103 beats/minute, blood pressure was 116/70 mmHg, and respiratory rate was 20 breaths/minute. She had no abnormal findings of her head, ears, eyes, nose, throat, heart, lungs, and abdomen. The only abnormal sign was bilateral pitting edema 3+ below the knee without erythema and increased warmth.\nRoutine laboratory tests showed that she had a mild microcytic anemia (hemoglobin 9.4 mg/dl, mean corpuscular volume 73 fl). Her serum total protein and albumin concentrations were low, but she had hyperglobulinemia and raised liver enzymes (aspartate aminotransferase, alanine aminotransferase, and alkaline phosphatase). Her serum creatinine was 0.82 mg/dl, for an estimated glomerular filtration rate (eGFR) of 85.49 ml/min/1.73 m2, blood urea nitrogen (BUN) 21.20 mg/dl, sodium 137 mEq/L, potassium 4.0 mEq/L, and chloride 103 mEq/L. Her hepatitis (anti-hepatitis C virus antibodies, hepatitis B surface antigen) and human immunodeficiency virus serology results were negative.\nHer urine was yellow and turbid, and dipstick urinalysis (Roche Diagnostics, Mannheim, Germany) demonstrated a specific gravity of 1.021, pH 6.0, protein 3+, blood 3+, red blood cells 20–30 cells/high-power field (HPF), white blood cells 5–10 cells/HPF. Urine microcopy of the urine sediment showed few fine granular casts 0–1/low-power field (LPF) and coarse granular casts 5–10/LPF. By spot urine, her total protein and creatinine were 1.339.4 mg/dl and 143.79 mg/dl, respectively.\nSuspecting chronic kidney disease secondary to an autoimmune disease, we performed additional investigations, which revealed a positive antinuclear antibody. For the titer of 1280, it revealed the homogeneous and fine speckled patterns meanwhile the nucleolar, peripheral, and cytoplasm patterns were observed in the titer of less than 80. The patient’s C3 complement concentration was 50.0 mg/dl (normal 81–157 mg/dl), and her C4 complement concentration was < 8.0 mg/dl (normal 13–39 mg/dl). Her urinary protein excretion over 24 hours was 9.3 g, meeting the case definition of nephrotic proteinuria. The result of a second urine analysis was similar to that of the first analysis . The patient was diagnosed with clinically suspected SLE with lupus nephritis. A referral for a renal biopsy was made, and she was prescribed prednisolone 1 mg/kg. Two days later, a third urinalysis was performed . In addition to similar results as before, several rapidly moving, large, ovoid-shaped ciliated parasites were seen by video clip/light microscopy; these findings were confirmed by two additional microscopic analyses of her urine sediment. No antiparasitic treatment was given, and she was asked to come for follow-up 2 weeks later.\nAt follow-up, a fourth urine analysis was done , and a spot urine protein (1679.0 mg/dl) and creatinine (100.34 mg/dl) were measured. Serum BUN and creatinine were 37.5 and 1.48 mg/dl, respectively. Numerous motile, ciliated trophozoites were seen in three consecutive urine samples by wet preparation and Wright-Giemsa staining that were identified as B. coli . Three daily stool examinations by formalin-ethyl acetate concentration were negative for ova, cysts, and parasites. She was prescribed tetracycline 500 mg four times daily for 10 days, after which the result of a post-treatment urine examination was negative for B. coli.", + "fulltext_subclaims": [ + "The patient is a 48-year-old Thai woman.", + "She has congenital mutism.", + "She had a 3-month history of intermittent swelling of both lower limbs.", + "She did not report joint pain.", + "She did not report headache.", + "She did not report photophobia.", + "She did not report rash.", + "She did not report dyspnea.", + "She did not report orthopnea.", + "She did not report palpitations.", + "She did not report hair loss.", + "She did not report bowel symptoms.", + "Her appetite was normal.", + "She had no history of clinically significant underlying diseases.", + "She was not receiving any drug treatments.", + "She did not drink alcohol.", + "She did not smoke.", + "Her weight was 41 kg.", + "Her body temperature was 37.2 °C.", + "Her pulse rate was 103 beats/minute.", + "Her blood pressure was 116/70 mmHg.", + "Her respiratory rate was 20 breaths/minute.", + "She had bilateral pitting edema 3+ below the knee.", + "The edema was without erythema.", + "The edema was without increased warmth.", + "She had mild microcytic anemia with hemoglobin 9.4 mg/dl.", + "Her mean corpuscular volume was 73 fl.", + "Her serum total protein and albumin concentrations were low.", + "She had hyperglobulinemia.", + "Her aspartate aminotransferase was raised.", + "Her alanine aminotransferase was raised.", + "Her alkaline phosphatase was raised.", + "Her serum creatinine was 0.82 mg/dl.", + "Her estimated glomerular filtration rate was 85.49 ml/min/1.73 m2.", + "Her blood urea nitrogen was 21.20 mg/dl.", + "Her hepatitis B surface antigen was negative.", + "Her anti-hepatitis C virus antibodies were negative.", + "Her human immunodeficiency virus serology was negative.", + "Her urine was yellow and turbid.", + "Dipstick urinalysis showed protein 3+.", + "Dipstick urinalysis showed blood 3+.", + "Urinalysis showed red blood cells 20–30 cells/high-power field.", + "Urinalysis showed white blood cells 5–10 cells/high-power field.", + "Urine sediment showed few fine granular casts 0–1/low-power field.", + "Urine sediment showed coarse granular casts 5–10/low-power field.", + "Her spot urine protein was 1339.4 mg/dl.", + "Her spot urine creatinine was 143.79 mg/dl.", + "She was suspected of having chronic kidney disease secondary to an autoimmune disease.", + "She had a positive antinuclear antibody.", + "The antinuclear antibody titer was 1280.", + "The antinuclear antibody showed homogeneous and fine speckled patterns.", + "The nucleolar, peripheral, and cytoplasm patterns were observed in the titer of less than 80.", + "Her C3 complement concentration was 50.0 mg/dl.", + "Her C4 complement concentration was < 8.0 mg/dl.", + "Her 24-hour urinary protein excretion was 9.3 g.", + "She met the case definition of nephrotic proteinuria.", + "The result of a second urine analysis was similar to that of the first analysis.", + "She was diagnosed with clinically suspected SLE with lupus nephritis.", + "A referral for a renal biopsy was made.", + "She was prescribed prednisolone 1 mg/kg.", + "Two days later, a third urinalysis was performed.", + "Several rapidly moving, large, ovoid-shaped ciliated parasites were seen in her urine sediment.", + "The findings were confirmed by two additional microscopic analyses.", + "No antiparasitic treatment was given.", + "She was asked to come for follow-up 2 weeks later.", + "At follow-up, a fourth urine analysis was done.", + "Her spot urine protein was 1679.0 mg/dl.", + "Her spot urine creatinine was 100.34 mg/dl.", + "Her serum BUN was 37.5 mg/dl.", + "Her serum creatinine was 1.48 mg/dl.", + "Numerous motile, ciliated trophozoites were seen in three consecutive urine samples.", + "The trophozoites were identified as B. coli.", + "Three daily stool examinations were negative for ova, cysts, and parasites.", + "She was prescribed tetracycline 500 mg four times daily for 10 days.", + "The post-treatment urine examination was negative for B. coli." + ], + "summary": "We present a case of a 48-year-old Thai woman who presented with nephrotic syndrome due to systemic lupus erythematosus-related nephritis. Initially, few B. coli cysts were found in urine sediment, but these increased substantially following treatment with prednisolone. She made an uneventful recovery with 10 days of oral tetracycline therapy. No B. coli cysts were found in her stool.", + "summary_subclaims": [ + "The patient was a 48-year-old Thai woman.", + "She presented with nephrotic syndrome due to systemic lupus erythematosus-related nephritis.", + "Initially, few B. coli cysts were found in urine sediment.", + "B. coli cysts increased substantially following treatment with prednisolone.", + "She made an uneventful recovery with 10 days of oral tetracycline therapy.", + "No B. coli cysts were found in her stool." + ] + }, + { + "id": "multiclinsum_test_1184_en.txt", + "fulltext": "A 68-year-old man was examined in the outpatient department of our hospital by transoesophageal echocardiogram (TOE) because the attending cardiologist suspected mitral valve endocarditis. The patient’s medical history revealed permanent AF, drug-, and hepatitis E-induced liver cirrhosis (CHILD Score B) being on vitamin-K-antagonist (VKA), a biological aortic valve replacement in 2011 and long-standing hypertension. Due to a history of cirrhosis-associated major gastric bleeding complications in February 2014, while being on VKA and rheumatoid arthritis with long-term glucocorticoid therapy, an LAA closure procedure was planned 3 months later in our hospital. At that time, the patient had a CHA2DS2-VASc score of 2 points (age 65–74 years +1 and hypertension +1) and a HAS-BLED score of 5 points (age, hypertension, abnormal liver function, labile International Normalized Ratio (INR), and prior major bleeding; each +1). Despite antihypertensive combination therapy, including a diuretic, the patient’s blood pressure remained increased. Therefore, in combination with the glucocorticoid therapy, the bleeding risk (estimated risk 9–12%) was substantially higher than the risk for ischaemic stroke (estimated at 2.2%). At the time, guidelines did not recommend direct oral anticoagulants as an alternative to VKA use as there was insufficient data. As a result, a percutaneous LAA closure was performed in May 2014 and a 33-mm WATCHMAN device was implanted in the LAA of a chicken wing type and a left atrial (LA) size of 22 cm2. The WATCHMAN device size was chosen based on a maximum LAA ostium size of 30 mm, for which a 33-mm WATCHMAN device is recommended. The manufacturer’s standard guidelines and recommendations were followed and the procedure was performed without any adverse events. Post-interventional TOE assessment showed an appropriate closure of the LAA. The patient was discharged with dual antiplatelet therapy (DAPT) comprising aspirin 100 mg/day and clopidogrel 75 mg/day for 3 months, to which he was compliant.\nIn July 2015, the patient was diagnosed with an ischaemic stroke due to the occlusion of the right internal carotid artery and carotid endarterectomy performed. A TOE performed at the time showed no intracardiac thrombus. Systemic lysis was performed, which resulted in intracranial bleeding. As a result, the CHA2DS2-VASc score increased to 4 points (age 65–74 years +1, hypertension +1, and stroke +2; estimated risk 4%) and the HAS-BLED score increased to 6 points [age, hypertension, abnormal liver function, labile INR, prior major bleeding, and (NEW) stroke; each +1 point; estimated risk higher than 9.1%], respectively. After conservative treatment, the patient was discharged to outpatient care with only slight neurological deficits (insecure gait) and his daily life was not impaired. The patient again received DAPT for 3 months, but no oral anticoagulation.\nIn April 2016, the patient was invited by the outpatient cardiologist for a routine transthoracic echocardiographic assessment, which included the evaluation of the prosthetic aortic valve function. Examination revealed a mobile mass towards the mitral valve, which was suspected to be potentially endocarditis-related. The size of the left atrium was only slightly larger than in 2014 (25 cm2). A TOE, which was performed shortly after hospital admission, confirmed this mobile mass (∼40 mm × 15 mm in size) arising from a cleft of the LAA and located between the pulmonary vein ridge and the LAA device itself . The structure periodically prolapsed through the mitral valve leaflets and was of dense texture with only minor mobility. Anticoagulation with partial thrombopplastin time (PTT)-controlled heparin (PTT 50–80 s) was initiated. The patient remained completely asymptomatic, without showing any clinical evidence of peripheral embolism or neurological event. Fever and elevation of serological inflammation markers were also absent. Because of the high bleeding risk with a HAS-BLED score of 5 points, surgery was chosen as the therapy of choice instead of long-term anticoagulation.\nThe patient was transferred to the cardiac surgery unit of a tertiary hospital and the device together with the thrombus was removed. Surgery was performed by a standard procedure with moderate hypothermia, utilizing a cardiopulmonary bypass manoeuvre, and by surgical closure of the LAA thereafter. In situ analysis showed that the closure did not cover the LAA completely and the device was only partially coated by the endothelium. A gap was identified between the device and the LAA from where the thrombus developed.\nOn Day 21 post-extirpation of the thrombus, the patient was discharged in good clinical condition on DAPT for the following 3 months. A TOE 6 weeks later showed no further thrombus formation and a completely closed LAA. In follow-ups at 6 and 12 months after surgery, transthoracic echocardiography was performed in an outpatient setting and did not reveal any clinically relevant findings. At this point, the patient was in a stable clinical condition. Further follow-up is planned on a yearly basis.", + "fulltext_subclaims": [ + "A 68-year-old man was examined in the outpatient department of our hospital by transoesophageal echocardiogram (TOE) because the attending cardiologist suspected mitral valve endocarditis.", + "The patient’s medical history revealed permanent AF.", + "The patient’s medical history revealed drug- and hepatitis E-induced liver cirrhosis (CHILD Score B).", + "The patient was on vitamin-K-antagonist (VKA).", + "The patient had a biological aortic valve replacement in 2011.", + "The patient had long-standing hypertension.", + "The patient had a history of cirrhosis-associated major gastric bleeding complications in February 2014.", + "The patient was on VKA and rheumatoid arthritis with long-term glucocorticoid therapy.", + "An LAA closure procedure was planned 3 months later in our hospital.", + "At that time, the patient had a CHA2DS2-VASc score of 2 points.", + "At that time, the patient had a HAS-BLED score of 5 points.", + "The estimated bleeding risk was 9–12%.", + "The estimated risk for ischaemic stroke was 2.2%.", + "Guidelines did not recommend direct oral anticoagulants as an alternative to VKA use.", + "A percutaneous LAA closure was performed in May 2014.", + "A 33-mm WATCHMAN device was implanted in the LAA.", + "The WATCHMAN device size was chosen based on a maximum LAA ostium size of 30 mm.", + "The manufacturer’s standard guidelines and recommendations were followed.", + "The procedure was performed without any adverse events.", + "Post-interventional TOE assessment showed an appropriate closure of the LAA.", + "The patient was discharged with dual antiplatelet therapy (DAPT) comprising aspirin 100 mg/day and clopidogrel 75 mg/day for 3 months.", + "In July 2015, the patient was diagnosed with an ischaemic stroke due to the occlusion of the right internal carotid artery.", + "A TOE performed at the time showed no intracardiac thrombus.", + "Systemic lysis was performed, which resulted in intracranial bleeding.", + "The CHA2DS2-VASc score increased to 4 points.", + "The HAS-BLED score increased to 6 points.", + "The patient was discharged to outpatient care with only slight neurological deficits.", + "The patient again received DAPT for 3 months, but no oral anticoagulation.", + "In April 2016, the patient was invited by the outpatient cardiologist for a routine transthoracic echocardiographic assessment.", + "Examination revealed a mobile mass towards the mitral valve.", + "A TOE confirmed this mobile mass (∼40 mm × 15 mm in size) arising from a cleft of the LAA.", + "The structure periodically prolapsed through the mitral valve leaflets.", + "The structure was of dense texture with only minor mobility.", + "Anticoagulation with PTT-controlled heparin was initiated.", + "The patient remained completely asymptomatic.", + "The patient showed no clinical evidence of peripheral embolism or neurological event.", + "Fever and elevation of serological inflammation markers were also absent.", + "Surgery was chosen as the therapy of choice instead of long-term anticoagulation.", + "The patient was transferred to the cardiac surgery unit of a tertiary hospital.", + "The device together with the thrombus was removed.", + "Surgery was performed by a standard procedure with moderate hypothermia.", + "Surgical closure of the LAA was performed.", + "In situ analysis showed that the closure did not cover the LAA completely.", + "The device was only partially coated by the endothelium.", + "A gap was identified between the device and the LAA from where the thrombus developed.", + "On Day 21 post-extirpation of the thrombus, the patient was discharged in good clinical condition.", + "A TOE 6 weeks later showed no further thrombus formation.", + "A TOE 6 weeks later showed a completely closed LAA.", + "In follow-ups at 6 and 12 months after surgery, transthoracic echocardiography did not reveal any clinically relevant findings.", + "At this point, the patient was in a stable clinical condition.", + "Further follow-up is planned on a yearly basis." + ], + "summary": "Here, we present a case of a 68-year-old male patient with permanent AF, drug- and hepatitis induced liver cirrhosis (CILD Score B), and prior aortic valve replacement. The patient had a history of percutaneous LAA closure using a WATCHMAN device. He developed massive peri-device leak and thrombus arising from the space between the device and appendage cleft 2 years after implantation. Because of the high bleeding risk with a HAS-BLED score of 5 points, surgery was chosen as the therapy of choice instead of long-term anticoagulation. The patient was discharged in good clinical condition and has been scheduled for a yearly follow-up.", + "summary_subclaims": [ + "The patient is a 68-year-old male.", + "The patient has permanent atrial fibrillation.", + "The patient has drug- and hepatitis induced liver cirrhosis.", + "The patient has a CILD Score B.", + "The patient had prior aortic valve replacement.", + "The patient had percutaneous left atrial appendage closure using a WATCHMAN device.", + "The patient developed massive peri-device leak.", + "The patient had a thrombus arising from the space between the device and appendage cleft.", + "The thrombus developed 2 years after implantation.", + "The patient had a HAS-BLED score of 5 points.", + "Surgery was chosen as the therapy of choice.", + "The patient was discharged in good clinical condition.", + "The patient has been scheduled for yearly follow-up." + ] + }, + { + "id": "multiclinsum_test_1970_en.txt", + "fulltext": "A 10-year-old Ethiopian boy presented to Tikur Anbessa Specialized Hospital, Addis Ababa, Ethiopia, with a sudden onset of weakness over his lower extremities. It had started 10 days earlier, accompanied by incontinence of urine and feces. He also had long-standing epigastric pain. He had no fever, diarrhea, cough, unconsciousness, abnormal body movements, or trauma. He had no close contact with a chronic cougher. He had received all scheduled vaccines during infancy, including four doses of oral polio vaccine, except hepatitis B vaccine, because he was born 1 year earlier than the incorporation of a routine three-dose series of hepatitis B vaccines into the national vaccination schedule. (He presented to our center in 2016.) Upon examination, he had an axillary temperature of 38.0 °C and tachycardia (115 beats per minute). He had a hard and tender hepatomegaly of 16-cm total span (10 cm below the right costal margin). Neurologic examination revealed a sensory level at T10, power of 0/5 of bilateral lower extremities, areflexia, and hypotonic anal tone.\nInvestigations confirmed a normal complete blood count and erythrocyte sedimentation rate of 25 mm/hr. The patient’s liver enzymes were elevated: alanine aminotransferase 160 U/L and aspartate aminotransferase 136 U/L. Alkaline phosphatase was 761 U/L, and serum albumin was 3.4 mg/dl. His coagulation profile, renal function, serum electrolytes, blood and urine cultures, and human immunodeficiency virus and hepatitis C serologies were negative. His hepatitis B surface antigen was positive. Additional serologic testing to identify the state of his hepatitis B infection was not accessible.\nThoracolumbar magnetic resonance imaging outlined a T9 vertebral body collapse with marrow signal change showing T1 isointensity and T2 heterogeneous hyperintensity. An epidural and paravertebral soft tissue swelling extending from T7 to T11 with postcontrast enhancement was seen to significantly compress the spinal cord. Differential diagnoses of tuberculosis spondylitis and metastases were considered.\nWorkup for a primary malignancy showed elevated serum lactate dehydrogenase (599 U/L) but normal serum uric acid, chest x-ray, and abdominal ultrasound. Computed tomography of the abdomen revealed multiple well-defined, different-sized, solid hepatic masses with invasion and thrombosis of the right portal vein branch. The liver had a heterogeneous attenuation. The thoracic vertebral body had collapsed with an adjacent soft tissue mass extending into the spinal canal and prevertebral space.\nSerum α-fetoprotein (AFP) was greater than 40,000 IU/L, and an ultrasound-guided fine needle aspirate showed moderately pleomorphic polygonal cells with round nuclei and ample granular eosinophilic cytoplasm. Thus, a diagnosis of HCC with vertebral metastases was confirmed. The boy’s parents were counseled on the prognosis of the illness, following which they decided against further medical care and opted for home palliative care.", + "fulltext_subclaims": [ + "A 10-year-old Ethiopian boy presented to Tikur Anbessa Specialized Hospital, Addis Ababa, Ethiopia, with a sudden onset of weakness over his lower extremities.", + "The weakness had started 10 days earlier.", + "The weakness was accompanied by incontinence of urine and feces.", + "He had long-standing epigastric pain.", + "He had no fever.", + "He had no diarrhea.", + "He had no cough.", + "He had no unconsciousness.", + "He had no abnormal body movements.", + "He had no trauma.", + "He had no close contact with a chronic cougher.", + "He had received all scheduled vaccines during infancy, including four doses of oral polio vaccine.", + "He had not received the hepatitis B vaccine.", + "He was born 1 year earlier than the incorporation of a routine three-dose series of hepatitis B vaccines into the national vaccination schedule.", + "He presented to our center in 2016.", + "Upon examination, he had an axillary temperature of 38.0 °C.", + "He had tachycardia (115 beats per minute).", + "He had a hard and tender hepatomegaly of 16-cm total span.", + "Neurologic examination revealed a sensory level at T10.", + "Neurologic examination revealed power of 0/5 of bilateral lower extremities.", + "Neurologic examination revealed areflexia.", + "Neurologic examination revealed hypotonic anal tone.", + "Investigations confirmed a normal complete blood count.", + "The erythrocyte sedimentation rate was 25 mm/hr.", + "The patient’s alanine aminotransferase was 160 U/L.", + "The patient’s aspartate aminotransferase was 136 U/L.", + "Alkaline phosphatase was 761 U/L.", + "Serum albumin was 3.4 mg/dl.", + "His coagulation profile was negative.", + "His renal function was normal.", + "His serum electrolytes were normal.", + "Blood and urine cultures were negative.", + "Human immunodeficiency virus serology was negative.", + "Hepatitis C serology was negative.", + "His hepatitis B surface antigen was positive.", + "Additional serologic testing to identify the state of his hepatitis B infection was not accessible.", + "Thoracolumbar magnetic resonance imaging outlined a T9 vertebral body collapse.", + "The T9 vertebral body collapse showed marrow signal change with T1 isointensity.", + "The T9 vertebral body collapse showed T2 heterogeneous hyperintensity.", + "An epidural and paravertebral soft tissue swelling extending from T7 to T11 with postcontrast enhancement was seen.", + "The epidural and paravertebral soft tissue swelling significantly compressed the spinal cord.", + "Differential diagnoses of tuberculosis spondylitis and metastases were considered.", + "Workup for a primary malignancy showed elevated serum lactate dehydrogenase (599 U/L).", + "Computed tomography of the abdomen revealed multiple well-defined, different-sized, solid hepatic masses.", + "The hepatic masses showed invasion and thrombosis of the right portal vein branch.", + "The liver had a heterogeneous attenuation.", + "The thoracic vertebral body had collapsed with an adjacent soft tissue mass extending into the spinal canal.", + "The thoracic vertebral body had an adjacent soft tissue mass extending into the prevertebral space.", + "Serum α-fetoprotein was greater than 40,000 IU/L.", + "An ultrasound-guided fine needle aspirate showed moderately pleomorphic polygonal cells.", + "The fine needle aspirate showed round nuclei.", + "The fine needle aspirate showed ample granular eosinophilic cytoplasm.", + "A diagnosis of HCC with vertebral metastases was confirmed.", + "The boy’s parents were counseled on the prognosis of the illness.", + "The boy’s parents decided against further medical care.", + "The boy’s parents opted for home palliative care." + ], + "summary": "We report on a case of a 10-year-old Ethiopian boy with hepatitis B infection presenting with paraplegia and incontinence of 10 days' duration. A diagnosis of hepatocellular carcinoma with vertebral metastases was confirmed with serum α-fetoprotein, fine-needle aspirate cytology, and abdominal imaging.", + "summary_subclaims": [ + "The patient is a 10-year-old Ethiopian boy.", + "The patient has hepatitis B infection.", + "The patient presented with paraplegia.", + "The patient presented with incontinence.", + "The duration of symptoms was 10 days.", + "A diagnosis of hepatocellular carcinoma with vertebral metastases was confirmed.", + "Serum α-fetoprotein was used to confirm the diagnosis.", + "Fine-needle aspirate cytology was used to confirm the diagnosis.", + "Abdominal imaging was used to confirm the diagnosis." + ] + }, + { + "id": "multiclinsum_test_2699_en.txt", + "fulltext": "A 75-year-old woman from Ghana with medical comorbidities of hypertension (not on an ACE inhibitor) and chronic cough was referred to our gastroenterology (GI) clinic for management of suspected gastroesophageal reflux disease (GERD) as the cause of chronic cough. As per the patient, she had been having a chronic cough for more than ten years. The cough was nonproductive, without any aggravating or relieving factors. She had reported postprandial heartburn. She recalls that cough started before her heartburn. She reported using albuterol and proton pump inhibitors (PPIs) without improvement in her cough. She did notice some improvement in her heartburn. She had never smoked, and her PPD was negative. There was no prior or current occupational exposure or pet exposure.\nShe underwent extensive otolaryngology evaluation including a laryngoscopy that showed evidence of chronic laryngopharyngeal reflux. She had been evaluated by pulmonologist and underwent spirometry, imaging studies, bronchoscopy, and fractional exhaled nitric oxide (FENO) testing and all the test results were normal.\nShe had been prescribed various therapies including oral, nasal, and inhaled corticosteroids, montelukast, and proton pump inhibitors without any improvement in cough.\nBecause of her typical GERD symptoms, she had a 48-hour Bravo pH testing done in 2011. The study revealed 4.9% of the time with pH below 4 and a total of 106 reflux episodes consistent with GERD. She was evaluated for the surgical intervention, and as a preoperative work-up, high-resolution esophageal manometry was performed. The manometric finding consistent with GERD revealed a hypotensive lower esophageal sphincter (LES). Subsequently, the patient underwent laparoscopic Nissen's fundoplication in 2012.\nAfter fundoplication, she was symptom-free. However, in few months her cough recurred but absence of heartburn and overt acid reflux symptoms was intriguing. She again sought evaluation for cough. She underwent EGD and Bravo pH testing in 2013. There was no evidence of esophagitis and the endoscopic evidence of the fundoplication was appreciated. The ambulatory pH test revealed 0.1% of total acid exposure time and no symptom correlation. She had moved to Ghana for a brief period and did not seek any medical attention. She continued her PPI with no significant improvement.\nGastroenterology consultation was sought again as the cough persisted. The physical examination including vital signs was unremarkable. She underwent a repeat Bravo pH study in February 2018 that revealed zero acid exposure and the study was not consistent with GERD ( and ).\nSubsequently, a high-resolution esophageal manometry was done in April 2018 with the findings indicating ineffective esophageal motility .\nA second opinion was sought from the gastrointestinal motility expert for the medical management of ineffective esophageal motility disorder. Given the absence of dysphagia, she was not considered a good candidate for medical management. To rule out nonacid reflux as a possible etiology of recurrent cough, patient was offered 24-hour Multichannel intraluminal impedance (MII) assisted pH monitoring. However, given the chronic cough and nasal discomfort, patient declined further intervention. Repeat laryngoscopy revealed laryngeal edema. To better assist with esophageal clearance, she was recommended to take frequent sips of water. She was suggested to carry a water bottle and take 1 to 2 sips of water every 15 minutes. Subsequently, patient presented to our clinic for a follow-up visit and was excited to report that her cough after years of work-up and medication use had finally subsided. She reported compliance with frequent sips of water. Patient had multiple interval follow-up for next 6 months where she reported continued absence of cough with multiple sips of water during the day.", + "fulltext_subclaims": [ + "The patient is a 75-year-old woman from Ghana.", + "She has medical comorbidities of hypertension and chronic cough.", + "She is not on an ACE inhibitor.", + "She was referred to gastroenterology for suspected GERD as the cause of chronic cough.", + "She had a chronic cough for more than ten years.", + "The cough was nonproductive.", + "She reported postprandial heartburn.", + "She recalls that cough started before her heartburn.", + "She reported using albuterol and proton pump inhibitors without improvement in her cough.", + "She did notice some improvement in her heartburn.", + "She had never smoked.", + "Her PPD was negative.", + "She had no prior or current occupational exposure or pet exposure.", + "She underwent laryngoscopy that showed evidence of chronic laryngopharyngeal reflux.", + "She had spirometry, imaging studies, bronchoscopy, and FENO testing, and all test results were normal.", + "She had been prescribed oral, nasal, and inhaled corticosteroids, montelukast, and proton pump inhibitors without any improvement in cough.", + "She had 48-hour Bravo pH testing in 2011.", + "The study revealed 4.9% of the time with pH below 4.", + "The study revealed a total of 106 reflux episodes consistent with GERD.", + "High-resolution esophageal manometry was performed as part of preoperative work-up.", + "The manometric finding consistent with GERD revealed a hypotensive lower esophageal sphincter.", + "She underwent laparoscopic Nissen's fundoplication in 2012.", + "After fundoplication, she was symptom-free.", + "In few months, her cough recurred.", + "She underwent EGD and Bravo pH testing in 2013.", + "There was no evidence of esophagitis.", + "The ambulatory pH test revealed 0.1% of total acid exposure time.", + "The ambulatory pH test showed no symptom correlation.", + "She had a repeat Bravo pH study in February 2018.", + "The study revealed zero acid exposure.", + "The study was not consistent with GERD.", + "A high-resolution esophageal manometry was done in April 2018.", + "The findings indicated ineffective esophageal motility.", + "A second opinion was sought from a gastrointestinal motility expert.", + "Given the absence of dysphagia, she was not considered a good candidate for medical management.", + "She was offered 24-hour MII assisted pH monitoring.", + "She declined further intervention.", + "Repeat laryngoscopy revealed laryngeal edema.", + "She was recommended to take frequent sips of water.", + "She was suggested to carry a water bottle and take 1 to 2 sips of water every 15 minutes.", + "She reported compliance with frequent sips of water.", + "She reported that her cough had finally subsided.", + "She had multiple interval follow-up visits over the next 6 months.", + "She reported continued absence of cough with multiple sips of water during the day." + ], + "summary": "A 75-year-old woman from Ghana was evaluated for GERD associated chronic cough. A 48-hour ambulatory pH study revealed acid exposure of 4.9% and high-resolution manometry showed decreased lower esophageal sphincter pressure, an inadequate response to medical and surgical management of GERD. Postfundoplication ambulatory pH testing demonstrated well-controlled acid reflux but her cough still persisted. Repeat manometry showed an ineffective motility disorder (IEM). Taking frequent sips of water eventually resolved her chronic cough.", + "summary_subclaims": [ + "The patient is a 75-year-old woman from Ghana.", + "The patient was evaluated for GERD associated chronic cough.", + "A 48-hour ambulatory pH study revealed acid exposure of 4.9%.", + "High-resolution manometry showed decreased lower esophageal sphincter pressure.", + "The patient had an inadequate response to medical and surgical management of GERD.", + "Postfundoplication ambulatory pH testing demonstrated well-controlled acid reflux.", + "The patient's cough still persisted.", + "Repeat manometry showed an ineffective motility disorder.", + "Taking frequent sips of water eventually resolved her chronic cough." + ] + }, + { + "id": "multiclinsum_test_864_en.txt", + "fulltext": "A 32 year old woman, gravida three para one with a history of cervical incompetence, polycystic ovarian syndrome, antiphospholipid antibody syndrome (APLS), and tubal factor infertility, conceived with frozen embryo transfer of a single blastocyst resulting from standard insemination technique; intracellular sperm injection was not performed. They did not opt for preimplantation genetic screening. The embryo was originally frozen in 2013, 2 years before the first identification of a Zika case in Haiti. Embryo transfer occurred in April of 2016. Her husband was actively traveling back and forth to Haiti for work before and during the pregnancy.\nHer history of two mid-trimester losses was managed with an abdominal cerclage placed pre-pregnancy. She was treated with prophylactic low molecular weight heparin for APLS and insulin for her type two diabetes mellitus. She received betamethasone in the early third trimester for an episode of threated preterm labor. At delivery she was euglycemic.\nEndemic Zika was identified in Haiti per the CDC early in the epidemic . When recommendations were issued regarding the possibility of sexual transmission of Zika virus in August 2016, her maternal fetal medicine provider counseled her to use condoms or refrain from intercourse with her husband, whose business travel continued through the pregnancy . She herself never left the greater Boston area prior to or during the pregnancy. She had not been to her native Haiti in over 10 years. There has never been any local transmission of Zika virus in the state of Massachusetts. Additionally, interview with the couple after delivery confirmed that neither of them ever experienced any symptoms of Zika infection. In the absence of symptoms in either partner, it was not our practice to recommend Zika serology during the pregnancy to screen for sexual exposure.\nThe patient underwent extensive fetal surveillance because of her multiple morbidities. She had a level II fetal survey at 18 weeks that revealed normal intracranial anatomy and head circumference (HC), and occipitofrontal diameter (OFD) measuring only 2 days smaller than her best dates. Biometry performed at 29 and 33 weeks was normal, and neither the HC nor the OFD measured less than 5%ile for gestational age. There was never any evidence of intracranial calcifications, ventriculomegaly, or abnormal posturing on antenatal ultrasound. She delivered in the 37th week via scheduled cesarean section. Her baby boy had APGARs of 8 (− 2 for color) and 9 (− 1 for color) at 1 and 5 min. He weighed 2775 g (30%ile by Fenton curve), was 49.5 cm long (65%ile) and had a head circumference of 29.2 cm (0%ile). The placenta was sent for conventional pathologic analysis given the maternal comorbidities. In addition, in light of the small measured neonatal HC and possible Zika virus sexual exposure, samples were sent to the CDC for evaluation. The timing of the IVF cycle relative to the Zika epidemic in Haiti was discussed with the Massachusetts Department of Public Health and CDC at length and the frozen embryo was determined not to be the source of infection.\nThe baby had a normal hearing screen and was discharged on day of life (DOL) 6. His workup for microcephaly included serum and urine Zika RT-PCR and IgM, both of which were ultimately negative; CMV, head ultrasound and MRI were also negative. Head ultrasound performed in the first week of life was notable for bilateral mineralizing vasculopathy but no intraparenchymal calcifications and otherwise normal anatomy. A subsequent head MRI was normal. The mother was rubella immune and had negative testing for other relevant TORCH infections. Approximately 3 months after delivery, confirmation was received from the CDC that all placental samples were positive for Zika RNA, thus supporting the diagnosis of congenital Zika syndrome. By the time the placental results from the CDC had been received, both parents were too far removed from the time of suspected infection to be able to do serology. HC at a pediatric visit shortly after receipt of the CDC report revealed an interval increase in HC, although it was still less than third percentile for his age. The child continues to meet normal pediatric milestones and receives early intervention services as well as assessment by pediatric neurodevelopment specialists. A genetics evaluation will be pursued if there is any lag in his neurodevelopment.", + "fulltext_subclaims": [ + "The patient is a 32 year old woman.", + "She is gravida three para one.", + "She has a history of cervical incompetence.", + "She has a history of polycystic ovarian syndrome.", + "She has a history of antiphospholipid antibody syndrome.", + "She has a history of tubal factor infertility.", + "She conceived with frozen embryo transfer of a single blastocyst.", + "The embryo was obtained via standard insemination technique.", + "Intracellular sperm injection was not performed.", + "They did not opt for preimplantation genetic screening.", + "The embryo was originally frozen in 2013.", + "The first identification of a Zika case in Haiti occurred 2 years after the embryo was frozen.", + "Embryo transfer occurred in April of 2016.", + "Her husband was actively traveling back and forth to Haiti for work before and during the pregnancy.", + "She had two mid-trimester losses.", + "She had an abdominal cerclage placed pre-pregnancy.", + "She was treated with prophylactic low molecular weight heparin for APLS.", + "She was treated with insulin for type two diabetes mellitus.", + "She received betamethasone in the early third trimester for an episode of threated preterm labor.", + "At delivery, she was euglycemic.", + "Endemic Zika was identified in Haiti per the CDC early in the epidemic.", + "Recommendations regarding the possibility of sexual transmission of Zika virus were issued in August 2016.", + "Her maternal fetal medicine provider counseled her to use condoms or refrain from intercourse with her husband.", + "Her husband's business travel continued through the pregnancy.", + "She never left the greater Boston area prior to or during the pregnancy.", + "There has never been any local transmission of Zika virus in the state of Massachusetts.", + "Neither she nor her husband experienced any symptoms of Zika infection.", + "In the absence of symptoms in either partner, it was not their practice to recommend Zika serology during the pregnancy.", + "She underwent extensive fetal surveillance.", + "She had a level II fetal survey at 18 weeks.", + "The level II fetal survey at 18 weeks revealed normal intracranial anatomy.", + "The occipitofrontal diameter measured only 2 days smaller than her best dates.", + "Biometry performed at 29 and 33 weeks was normal.", + "There was never any evidence of intracranial calcifications.", + "There was never any evidence of ventriculomegaly.", + "There was never any evidence of abnormal posturing on antenatal ultrasound.", + "She delivered in the 37th week via scheduled cesarean section.", + "The baby had APGARs of 8 (− 2 for color) at 1 min.", + "The baby had APGARs of 9 (− 1 for color) at 5 min.", + "The baby weighed 2775 g.", + "The baby's head circumference was 29.2 cm.", + "The placenta was sent for conventional pathologic analysis.", + "Samples were sent to the CDC for evaluation.", + "The frozen embryo was determined not to be the source of infection.", + "The baby had a normal hearing screen.", + "The baby was discharged on day of life 6.", + "The workup for microcephaly included serum and urine Zika RT-PCR.", + "The workup for microcephaly included IgM testing.", + "Zika RT-PCR and IgM were negative.", + "CMV testing was negative.", + "Head ultrasound performed in the first week of life was notable for bilateral mineralizing vasculopathy.", + "Head ultrasound showed no intraparenchymal calcifications.", + "A subsequent head MRI was normal.", + "The mother was rubella immune.", + "Testing for other relevant TORCH infections was negative.", + "Approximately 3 months after delivery, confirmation was received from the CDC that all placental samples were positive for Zika RNA.", + "HC at a pediatric visit shortly after receipt of the CDC report revealed an interval increase in HC.", + "The child continues to meet normal pediatric milestones.", + "The child receives early intervention services.", + "A genetics evaluation will be pursued if there is any lag in his neurodevelopment." + ], + "summary": "A 32 year-old woman who had not traveled to any area with local Zika transmission in years became pregnant via frozen embryo transfer. Her husband traveled to Haiti several times prior to embryo transfer and during the pregnancy. Neither partner was ever symptomatic. In her second trimester when recommendations were published by the Centers for Disease Control and Prevention (CDC) regarding prevention of sexual transmission during pregnancy she was counseled to abstain or use barrier protection with her partner. At delivery, the infant head circumference measured less than the first percentile. Placental samples were sent to the CDC and all were positive for Zika RNA by RT-PCR. Evaluation for other causes of microcephaly was negative. Consistent with the most up to date diagnostic parameters for congenital Zika, including viral infection of the placenta, the baby was diagnosed with congenital Zika syndrome.", + "summary_subclaims": [ + "The patient was a 32 year-old woman.", + "She had not traveled to any area with local Zika transmission in years.", + "She became pregnant via frozen embryo transfer.", + "Her husband traveled to Haiti several times prior to embryo transfer.", + "Her husband also traveled to Haiti during the pregnancy.", + "Neither partner was ever symptomatic.", + "In her second trimester, the CDC published recommendations regarding prevention of sexual transmission during pregnancy.", + "She was counseled to abstain or use barrier protection with her partner.", + "At delivery, the infant head circumference measured less than the first percentile.", + "Placental samples were sent to the CDC.", + "All placental samples were positive for Zika RNA by RT-PCR.", + "Evaluation for other causes of microcephaly was negative.", + "The baby was diagnosed with congenital Zika syndrome." + ] + }, + { + "id": "multiclinsum_test_2051_en.txt", + "fulltext": "A 75-year-old woman was admitted to the hospital with abdominal pain, nausea and vomiting for 3 days. She did not drink alcohol, and there was no clinical or biochemical evidence of primary liver disease or coagulopathy. Physical examination revealed mild tenderness in the right upper abdominal quadrant. Laboratory tests revealed that the percentage of neutrophils (N%) was 80.3% (50–70%), alanine aminotransferase (ALT) was 192 U/L (< 64 U/L), aspartate aminotransferase (AST) was 66 U/L (< 64 U/L), γ-glutamyl transpeptidase (γ-GT) was 197 U/L (< 47 U/L), and all other laboratory parameters were normal (e.g., haemoglobin and platelet counts, prothrombin time, and renal function). An abdominal computerized tomography (CT) scan demonstrated dilatation of the extrahepatic bile duct with a stone at the lower CBD and sludge in the gallbladder. Bile duct cholangiopancreatography revealed a dilated CBD (10 mm in diameter) with a round filling defect (8 mm in diameter) . Balloon dilation (10 mm in diameter) of terminal CBD after a 5-mm long sphincterotomy for extraction of the stone was uneventful. Unfortunately, she presented with cholangitis and a significant increase in the percentage of neutrophils (94%) and cholestatic parameters (total bilirubin 111.1 μmol/L (2–18 μmol/L), direct bilirubin 81.3 μmol/L (< 7 μmol/L), ALT 465 U/L, AST 538 U/L, and γ-GT 634 U/L) after 3 days.\nA high-density image of the middle CBD with a markedly dilated biliary tree was revealed on the second CT . Thus, ERCP was repeated. A long filling defect was noted in the dilated common bile duct , and a blood clot (maximum diameter 35 mm × 10 mm) was extracted with a basket . Then, an endoscopic nasobiliary drainage (ENBD) tube was inserted into the CBD to ensure continued biliary drainage. Two days later, her temperature returned to normal, and abdominal pain was relieved. Histopathological examination revealed massive red blood cells with white blood cells and tissue necrosis . After the treatment, she recovered and was discharged without any other complication.", + "fulltext_subclaims": [ + "The patient was a 75-year-old woman.", + "She had abdominal pain, nausea, and vomiting for 3 days.", + "She did not drink alcohol.", + "There was no clinical or biochemical evidence of primary liver disease.", + "There was no clinical or biochemical evidence of coagulopathy.", + "Physical examination revealed mild tenderness in the right upper abdominal quadrant.", + "The percentage of neutrophils (N%) was 80.3% (50–70%).", + "Alanine aminotransferase (ALT) was 192 U/L (< 64 U/L).", + "Aspartate aminotransferase (AST) was 66 U/L (< 64 U/L).", + "γ-Glutamyl transpeptidase (γ-GT) was 197 U/L (< 47 U/L).", + "An abdominal CT scan demonstrated dilatation of the extrahepatic bile duct.", + "An abdominal CT scan showed a stone at the lower CBD.", + "An abdominal CT scan showed sludge in the gallbladder.", + "Bile duct cholangiopancreatography revealed a dilated CBD (10 mm in diameter).", + "Bile duct cholangiopancreatography showed a round filling defect (8 mm in diameter).", + "Balloon dilation (10 mm in diameter) of terminal CBD after a 5-mm long sphincterotomy was uneventful.", + "She presented with cholangitis after 3 days.", + "The percentage of neutrophils increased to 94% after 3 days.", + "Total bilirubin was 111.1 μmol/L (2–18 μmol/L) after 3 days.", + "Direct bilirubin was 81.3 μmol/L (< 7 μmol/L) after 3 days.", + "ALT was 465 U/L after 3 days.", + "AST was 538 U/L after 3 days.", + "γ-GT was 634 U/L after 3 days.", + "A high-density image of the middle CBD with a markedly dilated biliary tree was revealed on the second CT.", + "ERCP was repeated.", + "A long filling defect was noted in the dilated common bile duct.", + "A blood clot (maximum diameter 35 mm × 10 mm) was extracted with a basket.", + "An endoscopic nasobiliary drainage (ENBD) tube was inserted into the CBD.", + "Her temperature returned to normal two days after the treatment.", + "Abdominal pain was relieved two days after the treatment.", + "Histopathological examination revealed massive red blood cells with white blood cells.", + "Histopathological examination revealed tissue necrosis.", + "She recovered and was discharged without any other complication." + ], + "summary": "We herein report a case of exceptional post-ERCP cholangitis due to a blood clot in the common bile duct (CBD). This case involves a 75-year-old woman with a history of recurring upper abdominal pain. Abdominal computerized tomography (CT) revealed dilatation of the extrahepatic bile duct with stones at the lower CBD. After ERCP, clearance of stones was obtained. The post-ERCP course was symptomatic with upper abdominal pain and a significant increase in cholestatic parameters. A second CT scan demonstrated a markedly dilated biliary tree with a longitudinal high-density image at the middle CBD. The patient was successfully treated with a repeated ERCP, and a blood clot was extracted. We also present a review of the literature published between 1985 and 2016 in PubMed. Four similar cases were reported during this period from France, Turkey, the USA and the UK, separately. Our case is the first reported in China.", + "summary_subclaims": [ + "We herein report a case of exceptional post-ERCP cholangitis due to a blood clot in the common bile duct (CBD).", + "This case involves a 75-year-old woman with a history of recurring upper abdominal pain.", + "Abdominal computerized tomography (CT) revealed dilatation of the extrahepatic bile duct with stones at the lower CBD.", + "After ERCP, clearance of stones was obtained.", + "The post-ERCP course was symptomatic with upper abdominal pain and a significant increase in cholestatic parameters.", + "A second CT scan demonstrated a markedly dilated biliary tree with a longitudinal high-density image at the middle CBD.", + "The patient was successfully treated with a repeated ERCP, and a blood clot was extracted.", + "We also present a review of the literature published between 1985 and 2016 in PubMed.", + "Four similar cases were reported during this period from France, Turkey, the USA and the UK, separately.", + "Our case is the first reported in China." + ] + }, + { + "id": "multiclinsum_test_708_en.txt", + "fulltext": "A 75 year old Caucasian male with a long history of retinal changes was seen in the clinic. He had initially presented 31 years earlier, in 1985, with pigmentary changes at the macula noted by his optician. At the time his best corrected visual acuity (BCVA) was 6/9 in the right eye and 6/6 in the left eye. Fundoscopy showed pigmentary changes and drusen which were more easily visible on intravenous fundus fluorescein angiography (IVFA) . There was no evidence of any choroidal neovascular membrane (CNVM) on any of the images. The patient underwent multiple further IVFA examinations, each time demonstrating no active leak. His retinal appearance was monitored, with no conclusive diagnosis made, nor treatment available.\nTen years later ongoing review identified that the patient had raised intraocular pressure along with optic disc changes and a diagnosis of glaucoma was made with appropriate treatment initiated. Subsequently, in 2001, the patient was diagnosed with hypertension (186/110 mmHg) which, at the time, was thought to be essential hypertension. Retinal examination demonstrated cotton wool spots and haemorrhages, consistent with hypertensive retinopathy . He was also noted to have elevated serum urea and creatinine levels which were assumed to be related to the diagnosis of hypertension.\nFollowing bilateral cataract surgery in 2003, which was complicated by posterior capsule rupture in the left eye, the patient was only able to achieve a BCVA of 6/36 in each eye. Due to inadequate control of IOP left sided trabeculectomy was performed in 2005.\nAt the same time, aged 64 years, the patient’s urea and creatinine levels were recorded as 20.5 mmol/L (normal 2.8–7.2 mmol/L) and 474umol/L (normal 60-105umol/L) respectively and he started regular haemo-dialysis for end stage renal failure shortly afterwards. He then underwent dual renal transplant in 2009 and was initiated on systemic immunosuppression (Tacrolimus 3 mg/day) which he continues to this day. The biopsy results from the explanted kidneys are unfortunately not available. Subsequently both transplanted kidneys failed over the coming year, with no identified cause, requiring the patient to undergo bilateral nephrostomies.\nIn June 2010 the patient was referred back to the Ophthalmology services, aged 69, with a presenting vision of 52 ETDRS (Early Treatment Diabetic Retinopathy Study) letters in the right eye and 35 letters in the left eye. He was again noted to have bilateral changes at the maculae which were, at the time, attributed to possible age related macular degeneration, and a small area of possible sub-retinal fluid. Comparison was made between the IVFA in 1985 and the IVFA at re-referral showing a significant increase in the number and distribution of the drusen, but no vascular leakage . The poor vision in the left eye was found to be secondary to advanced glaucoma and significant changes at the macula. No treatment was appropriate and the patient was monitored for 5 years with repeated Optical Coherence Tomography (OCT) scans.\nIn 2015 the OCT demonstrated an increasing sub-foveal space, raising a suspicion of CNVM. A loading phase of intravitreal anti vascular endothelial growth factor (anti-VEGF) was initiated in the form of Ranibizumab 0.5 mg. As there was no response to six Ranibizumab injections, treatment was subsequently switched to Aflibercept 2 mg with three further monthly doses. Again there was no improvement and treatment was ceased .\nDue to an unusual appearance and history when considering age related macular degeneration, a systematic review of his previous notes and images was performed as part of a retinal multi-disciplinary team.\nAt the most recent visit (October 2016) the patient’s BCVA was recorded in the right eye as 49 ETDRS letters and awareness of hand movements only in the left eye. The fundus examination demonstrated multiple subretinal drusenoid deposits, which were autofluorescent, mainly at the posterior pole. Careful review of the OCT images demonstrated that the deposits were in Bruch’s membrane, with an intact Retinal Pigment Epithelium (RPE) .\nAutofluorescence imaging demonstrated large areas of increased and decreased autofluorescence involving the macula and spreading inferiorly . OCT continued to demonstrate subfoveal hyporeflective areas. Pale optic discs were noted bilaterally, consistent with the long standing diagnosis of advanced glaucoma.\nWide angle (102°) infra-red imaging demonstrates the limitation of the retinal disease to the posterior pole, involving the macula, crossing the vascular arcades and including the nasal peri-papillary region .\nThe young age of presentation with drusen, recurrent kidney failure and increasing subretinal deposits , led to the suspicion of this being a probable case of dense deposit disease. He is currently being tested for serum C3 levels and C3 nephritic factor as well as genetic testing for a variety of mutations in complement associated genes, with the results awaited.", + "fulltext_subclaims": [ + "The patient is a 75 year old Caucasian male.", + "He had initially presented 31 years earlier, in 1985, with pigmentary changes at the macula noted by his optician.", + "At the time his best corrected visual acuity (BCVA) was 6/9 in the right eye and 6/6 in the left eye.", + "Fundoscopy showed pigmentary changes and drusen which were more easily visible on intravenous fundus fluorescein angiography (IVFA).", + "There was no evidence of any choroidal neovascular membrane (CNVM) on any of the images.", + "The patient underwent multiple further IVFA examinations, each time demonstrating no active leak.", + "His retinal appearance was monitored, with no conclusive diagnosis made.", + "Ten years later ongoing review identified that the patient had raised intraocular pressure along with optic disc changes and a diagnosis of glaucoma was made.", + "In 2001, the patient was diagnosed with hypertension (186/110 mmHg).", + "Retinal examination demonstrated cotton wool spots and haemorrhages, consistent with hypertensive retinopathy.", + "He was also noted to have elevated serum urea and creatinine levels which were assumed to be related to the diagnosis of hypertension.", + "Following bilateral cataract surgery in 2003, which was complicated by posterior capsule rupture in the left eye, the patient was only able to achieve a BCVA of 6/36 in each eye.", + "Due to inadequate control of IOP left sided trabeculectomy was performed in 2005.", + "At the same time, aged 64 years, the patient’s urea and creatinine levels were recorded as 20.5 mmol/L and 474umol/L respectively.", + "He started regular haemo-dialysis for end stage renal failure shortly afterwards.", + "He then underwent dual renal transplant in 2009 and was initiated on systemic immunosuppression (Tacrolimus 3 mg/day).", + "The biopsy results from the explanted kidneys are unfortunately not available.", + "Subsequently both transplanted kidneys failed over the coming year, with no identified cause, requiring the patient to undergo bilateral nephrostomies.", + "In June 2010 the patient was referred back to the Ophthalmology services, aged 69, with a presenting vision of 52 ETDRS letters in the right eye and 35 letters in the left eye.", + "He was again noted to have bilateral changes at the maculae which were, at the time, attributed to possible age related macular degeneration.", + "Comparison was made between the IVFA in 1985 and the IVFA at re-referral showing a significant increase in the number and distribution of the drusen, but no vascular leakage.", + "The poor vision in the left eye was found to be secondary to advanced glaucoma and significant changes at the macula.", + "No treatment was appropriate and the patient was monitored for 5 years with repeated Optical Coherence Tomography (OCT) scans.", + "In 2015 the OCT demonstrated an increasing sub-foveal space, raising a suspicion of CNVM.", + "A loading phase of intravitreal anti vascular endothelial growth factor (anti-VEGF) was initiated in the form of Ranibizumab 0.5 mg.", + "As there was no response to six Ranibizumab injections, treatment was subsequently switched to Aflibercept 2 mg with three further monthly doses.", + "Again there was no improvement and treatment was ceased.", + "At the most recent visit (October 2016) the patient’s BCVA was recorded in the right eye as 49 ETDRS letters and awareness of hand movements only in the left eye.", + "The fundus examination demonstrated multiple subretinal drusenoid deposits, which were autofluorescent, mainly at the posterior pole.", + "Careful review of the OCT images demonstrated that the deposits were in Bruch’s membrane, with an intact Retinal Pigment Epithelium (RPE).", + "Autofluorescence imaging demonstrated large areas of increased and decreased autofluorescence involving the macula and spreading inferiorly.", + "OCT continued to demonstrate subfoveal hyporeflective areas.", + "Pale optic discs were noted bilaterally, consistent with the long standing diagnosis of advanced glaucoma.", + "Wide angle (102°) infra-red imaging demonstrates the limitation of the retinal disease to the posterior pole, involving the macula, crossing the vascular arcades and including the nasal peri-papillary region.", + "The young age of presentation with drusen, recurrent kidney failure and increasing subretinal deposits led to the suspicion of this being a probable case of dense deposit disease.", + "He is currently being tested for serum C3 levels and C3 nephritic factor as well as genetic testing for a variety of mutations in complement associated genes, with the results awaited." + ], + "summary": "A 44 year old male presented with pigmentary changes at the macula noted by his optician. Best corrected visual acuity at presentation was good in both eyes. Fundoscopy showed pigmentary changes and drusen, and investigation using intravenous fundus fluorescein angiography did not demonstrate any choroidal neovascular membrane. The patient subsequently developed renal failure and received a dual renal transplant. The transplanted kidneys also failed over the coming year. The patient's vision gradually deteriorated and comparison between the images in 2010 and 1985 demonstrated a clear progression of the macula changes. Optical coherence tomography showed multiple subretinal hyper reflective drusenoid deposits. These deposits were also noted to be autofluorescent on blue auto-fluorescence. The young age at presentation of drusen, combined with the history of recurrent kidney failure and progression of subretinal deposits led to a diagnosis of dense deposit disease.", + "summary_subclaims": [ + "A 44 year old male presented with pigmentary changes at the macula noted by his optician.", + "Best corrected visual acuity at presentation was good in both eyes.", + "Fundoscopy showed pigmentary changes and drusen.", + "Intravenous fundus fluorescein angiography did not demonstrate any choroidal neovascular membrane.", + "The patient subsequently developed renal failure and received a dual renal transplant.", + "The transplanted kidneys also failed over the coming year.", + "The patient's vision gradually deteriorated.", + "Comparison between the images in 2010 and 1985 demonstrated a clear progression of the macula changes.", + "Optical coherence tomography showed multiple subretinal hyper reflective drusenoid deposits.", + "These deposits were also noted to be autofluorescent on blue auto-fluorescence.", + "The young age at presentation of drusen, combined with the history of recurrent kidney failure and progression of subretinal deposits led to a diagnosis of dense deposit disease." + ] + }, + { + "id": "multiclinsum_test_754_en.txt", + "fulltext": "A 75-year-old, male patient with metastatic RCC was admitted to our hospital with new-onset dysphagia and weight loss. His first surgical resection of RCC was a right nephrectomy with adrenalectomy which he underwent 20 years ago, and the second resection was a left partial nephrectomy for metachronous primary left RCC performed 12 years ago. Nine years later, computed tomography (CT) showed a 4-mm, early enhancing tumor in the pancreatic head and a 6-mm, early enhancing tumor in the pancreatic tail. PM-RCC was diagnosed. Total pancreatectomy was proposed, but he declined it. He also declined receiving tyrosine kinase inhibitors and interferon therapy was started. Although its adverse events were minimal, the patient discontinued the treatment on his own discretion. He declined any further anticancer drug therapy and was followed up every 3 months as an outpatient. The pancreatic metastases gradually increased in size and number, but were asymptomatic. Multiple pulmonary metastases also appeared 3 years ago, and dyslexia caused by a brain metastasis developed 9 months ago. The brain metastasis was resected 6 months ago. The patient also had a history of a total gastrectomy with Roux-en Y reconstruction and a splenectomy for gastric cancer 23 years earlier.\nHis oral intake of food was insufficient, and his Eastern Cooperative Oncology Group performance status was 2. The laboratory tests on the day before the operation showed the patient had mild anemia (Hb 9.1 g/dL) and hypoalbuminemia (Alb 2.6 g/dL). His blood coagulation, kidney and liver function, and electrolytes were normal. Esophagogastroduodenoscopy demonstrated a massive, reddish tumor on the distal side of the anastomotic site in the lumen of the jejunal limb . CT revealed that one of the metastases in the pancreatic tail had markedly enlarged compared with previous CT. PM-RCC invaded the jejunal limb and extended into the lumen. A tumor thrombus completely filled the jejunal limb, increasing its diameter to 7 cm. The proximal side of the jejunal limb had also expanded, with the tumor thrombus causing bowel occlusion . Although preoperative biopsy of the tumor was not performed because of concern about hemorrhagic complications, based on CT findings and course of tumor growth, jejunal limb obstruction due to a tumor thrombus from PM-RCC was diagnosed. The size and number of the pulmonary metastases were stable, and no new metastases were detected.\nPalliative surgery was considered as means of ameliorating the patient’s symptoms. However, because the tumor thrombus was located at a site immediately distal to the esophagojejunal anastomosis, bypass surgery would have been difficult. To remove the bowel occlusion, distal pancreatectomy with concomitant resection of the jejunal limb and re-anastomosis were considered to be necessary. Although the patient had multiple RCC metastases, his general condition remained fairly good, and tumor progression was slow. After the surgical indications were discussed in detail, palliative resection of the tumor thrombus was chosen as the method of treatment.\nExploratory abdominal surgery revealed no peritoneal metastases. First, adhesiolysis of the upper abdominal cavity was done. The jejunal limb showed enlargement due to the tumor thrombus, which extended from the pancreatic tail, and the jejunal wall showed thinning and pallor . Intraoperative sonography (IOUS) showed a massive pancreatic mass extending into the jejunal limb . To remove the patient’s symptoms, jejunal limb resection was performed concomitantly with a distal pancreatectomy. After dividing the pancreas using reinforced staples at the site closest to the tumor based on IOUS findings, the jejunal limb was resected from a point proximal to the jejunoesophageal anastomosis to the distal side of the tumor thrombus . The jejunal limb remnant was approximately 30 cm long and was re-anastomosed to the esophagus using circular staplers while avoiding excessive tension. Blood perfusion at the anastomotic site and transverse colon was confirmed by indocyanine green (ICG) fluorescence imaging .\nThe patient’s postoperative course was uneventful except for an intraabdominal infection, which was treated with intravenous antibiotics. He was discharged after achieving sufficient oral intake on postoperative day 24. Histologic examination revealed metastatic RCC of the pancreas involving the jejunum . At a follow-up examination in the outpatient clinic at postoperative 8 months, he had no gastrointestinal symptoms.", + "fulltext_subclaims": [ + "The patient is a 75-year-old male.", + "The patient has metastatic RCC.", + "The patient had a right nephrectomy with adrenalectomy 20 years ago.", + "The patient had a left partial nephrectomy for metachronous primary left RCC 12 years ago.", + "Nine years after the left partial nephrectomy, CT showed a 4-mm, early enhancing tumor in the pancreatic head.", + "Nine years after the left partial nephrectomy, CT showed a 6-mm, early enhancing tumor in the pancreatic tail.", + "PM-RCC was diagnosed.", + "Total pancreatectomy was proposed.", + "The patient declined total pancreatectomy.", + "The patient declined receiving tyrosine kinase inhibitors.", + "Interferon therapy was started.", + "The patient discontinued interferon therapy on his own discretion.", + "The patient declined any further anticancer drug therapy.", + "The pancreatic metastases gradually increased in size and number.", + "The pancreatic metastases were asymptomatic.", + "Multiple pulmonary metastases appeared 3 years ago.", + "Dyslexia caused by a brain metastasis developed 9 months ago.", + "The brain metastasis was resected 6 months ago.", + "The patient had a history of a total gastrectomy with Roux-en Y reconstruction.", + "The patient had a history of a splenectomy for gastric cancer 23 years earlier.", + "The patient's oral intake of food was insufficient.", + "The patient's Eastern Cooperative Oncology Group performance status was 2.", + "The patient had mild anemia (Hb 9.1 g/dL).", + "The patient had hypoalbuminemia (Alb 2.6 g/dL).", + "Blood coagulation, kidney and liver function, and electrolytes were normal.", + "Esophagogastroduodenoscopy demonstrated a massive, reddish tumor on the distal side of the anastomotic site in the lumen of the jejunal limb.", + "CT revealed that one of the metastases in the pancreatic tail had markedly enlarged compared with previous CT.", + "PM-RCC invaded the jejunal limb and extended into the lumen.", + "A tumor thrombus completely filled the jejunal limb, increasing its diameter to 7 cm.", + "The proximal side of the jejunal limb had also expanded, with the tumor thrombus causing bowel occlusion.", + "Preoperative biopsy of the tumor was not performed.", + "Jejunal limb obstruction due to a tumor thrombus from PM-RCC was diagnosed.", + "The size and number of the pulmonary metastases were stable.", + "No new metastases were detected.", + "Palliative surgery was considered as means of ameliorating the patient’s symptoms.", + "Bypass surgery would have been difficult.", + "Distal pancreatectomy with concomitant resection of the jejunal limb and re-anastomosis were considered necessary.", + "The patient had multiple RCC metastases.", + "The patient’s general condition remained fairly good.", + "Tumor progression was slow.", + "Palliative resection of the tumor thrombus was chosen as the method of treatment.", + "Exploratory abdominal surgery revealed no peritoneal metastases.", + "Adhesiolysis of the upper abdominal cavity was done.", + "The jejunal limb showed enlargement due to the tumor thrombus.", + "The tumor thrombus extended from the pancreatic tail.", + "The jejunal wall showed thinning and pallor.", + "Intraoperative sonography showed a massive pancreatic mass extending into the jejunal limb.", + "Jejunal limb resection was performed concomitantly with a distal pancreatectomy.", + "The pancreas was divided using reinforced staples at the site closest to the tumor based on IOUS findings.", + "The jejunal limb was resected from a point proximal to the jejunoesophageal anastomosis to the distal side of the tumor thrombus.", + "The jejunal limb remnant was approximately 30 cm long.", + "The jejunal limb remnant was re-anastomosed to the esophagus using circular staplers.", + "Blood perfusion at the anastomotic site and transverse colon was confirmed by indocyanine green fluorescence imaging.", + "The patient’s postoperative course was uneventful except for an intraabdominal infection.", + "The intraabdominal infection was treated with intravenous antibiotics.", + "The patient was discharged after achieving sufficient oral intake on postoperative day 24.", + "Histologic examination revealed metastatic RCC of the pancreas involving the jejunum.", + "At a follow-up examination in the outpatient clinic at postoperative 8 months, he had no gastrointestinal symptoms." + ], + "summary": "A 75-year-old, male patient with metastatic RCC was admitted to our hospital with new-onset dysphagia and weight loss. Twenty years earlier he underwent a right nephrectomy with an adrenalectomy for the first surgical resection of RCC, and 12 years ago he underwent a left partial nephrectomy for metachronous primary RCC. Nine years later, multiple pancreatic metastases were detected. After discontinuing interferon therapy, he was followed up at his request without anticancer treatment. Multiple, pulmonary metastases developed 3 years ago, and resection of a brain metastasis was performed 6 months ago. He had also undergone a total gastrectomy with Roux-en Y reconstruction and splenectomy for gastric cancer 23 years ago. Computed tomography revealed a metastatic lesion in the pancreatic tail extending into the jejunal limb, which was obstructed by a tumor thrombus. Jejunal limb resection was performed concomitantly with a distal pancreatectomy as palliative surgery. The jejunal limb remnant was approximately 30 cm long and was re-anastomosed to the esophagus using a circular stapler. Blood perfusion at the anastomotic site was confirmed by indocyanine green fluorescence imaging. He was discharged on postoperative day 24 and was followed in the outpatient clinic. He achieved sufficient oral intake at 8 months postoperatively.", + "summary_subclaims": [ + "The patient is a 75-year-old male.", + "The patient has metastatic RCC.", + "The patient was admitted with new-onset dysphagia.", + "The patient had weight loss.", + "Twenty years earlier, the patient underwent a right nephrectomy with an adrenalectomy.", + "The right nephrectomy was for the first surgical resection of RCC.", + "Twelve years ago, the patient underwent a left partial nephrectomy.", + "The left partial nephrectomy was for metachronous primary RCC.", + "Nine years after the left partial nephrectomy, multiple pancreatic metastases were detected.", + "The patient discontinued interferon therapy.", + "The patient was followed up without anticancer treatment.", + "The follow-up was at the patient's request.", + "Multiple pulmonary metastases developed 3 years ago.", + "A brain metastasis was resected 6 months ago.", + "The patient had a total gastrectomy with Roux-en Y reconstruction.", + "The gastrectomy was for gastric cancer.", + "The gastrectomy was performed 23 years ago.", + "Computed tomography revealed a metastatic lesion in the pancreatic tail.", + "The pancreatic lesion extended into the jejunal limb.", + "The jejunal limb was obstructed by a tumor thrombus.", + "Jejunal limb resection was performed.", + "A distal pancreatectomy was performed.", + "The surgery was palliative.", + "The jejunal limb remnant was approximately 30 cm long.", + "The jejunal limb remnant was re-anastomosed to the esophagus.", + "A circular stapler was used for the anastomosis.", + "Blood perfusion at the anastomotic site was confirmed.", + "Indocyanine green fluorescence imaging was used to confirm blood perfusion.", + "The patient was discharged on postoperative day 24.", + "The patient was followed in the outpatient clinic.", + "At 8 months postoperatively, the patient achieved sufficient oral intake." + ] + }, + { + "id": "multiclinsum_test_3388_en.txt", + "fulltext": "A 13-year-old-male with no known past medical history presented after being struck by a car. He presented with several orthopedic injuries: an open left humeral shaft fracture, left knee osteochondral fracture, and left open patella fracture. The patient was intubated and sedated on presentation to the emergency department, and therefore, a thorough neurovascular assessment could not be made. However, the patient had a palpable radial pulse. He was taken for open treatment of left patella fracture, irrigation and debridement to left open humeral wound, and surgical stabilization of left humerus fracture.\n\nAs for his left open humeral shaft fracture, the wound and constituent soft tissues were copiously irrigated and debrided. Intraoperatively, a mid-substance, complete intramuscular biceps tear was noted. The radial nerve was identified to be contused where it passed beyond the fracture site posteriorly; however, it was in full continuity throughout the course of the nerve. Next, the fracture was reduced and stabilized with a 4.5 mm narrow large fragment plate.\n\nAttention then was directed at open repair of the intramuscular, mid-substance biceps rupture. Proximal and distal ends were identified. Ethibond sutures were used in a running Krackow fashion while the elbow was held in hyperflexion. All six sutures were then tied with the proximal corresponding limb repaired to the distal corresponding limb. Once all six suture tails had been fully tensioned and tightened, the elbow was taken through a gentle range of motion from approximately 80 degrees short of full extension to full flexion with no noted gapping about the biceps repair site. Wound closure ensued, followed by placement into a splint in 100 degrees of flexion. Postoperatively, the patient was extubated and was observed to be distally neurovascularly intact in radial, ulnar, and median nerve distributions.\n\nNine days after the index surgery, the patient presented due to purulent drainage from the surgical wound. He was taken to the operating room for wound exploration and irrigation and debridement. Intraoperatively, it was noted that the biceps repair had failed. Deep tissue samples were sent for culture. The area was debrided, leaving a large soft tissue defect. A wound vac was then placed. He was placed on antibiotics postoperatively that were narrowed to ciprofloxacin once cultures speciated to Enterobacter and Citrobacter.\n\nHe was taken back to the operating room three days afterwards for a repeat wound exploration, repeat irrigation and debridement, revision open biceps repair, and wound closure. He was treated with oral ciprofloxacin per the pediatric infectious disease recommendations. He was made platform weight-bearing to the left upper extremity in a splint with a lateral side strut, with the arm flexed to 100 degrees to protect the intact brachialis muscle. At twelve days postoperatively, his wound was healing appropriately.\n\nAt his first postoperative visit 2.5 weeks after his first surgery (six days after the repeat debridement and revision open biceps repair), the surgical incision was healing well. At seven weeks after his first surgery (5.5 weeks since the repeat debridement and revision open biceps repair), plain film radiographs showed fracture healing and no hardware complications. At this time, his weight bearing status was advanced to weight bearing as tolerated for activities for daily living, and he began gentle active and passive range of motion exercises; occupational therapy for static dynamic extension splinting was also initiated. The patient returned at 14 weeks after his first surgery (12.5 weeks since the repeat debridement and revision open biceps repair) and was able to actively range his left elbow from full flexion to 10 degrees shy of full extension; he had full pronation and supination. At this visit, his weight bearing status was advanced to weight bearing as tolerated, except for heavy lifting.\n\nHe completed five total months of oral antibiotic therapy with ciprofloxacin. He was advanced to full weight bearing with no restrictions nine months after his index surgery. At this clinical visit, he lacked two degrees of terminal extension. Subsequently, at his most recent clinic visit (one year after his index surgery), he had full flexion/extension to the left elbow, 5/5 biceps, supination, and pronation strength, and was playing sports without limitation.", + "fulltext_subclaims": [ + "The patient was a 13-year-old-male with no known past medical history.", + "He presented after being struck by a car.", + "He had an open left humeral shaft fracture.", + "He had a left knee osteochondral fracture.", + "He had a left open patella fracture.", + "The patient was intubated and sedated on presentation.", + "A thorough neurovascular assessment could not be made.", + "The patient had a palpable radial pulse.", + "He was taken for open treatment of left patella fracture.", + "He was taken for irrigation and debridement to left open humeral wound.", + "He was taken for surgical stabilization of left humerus fracture.", + "The wound and constituent soft tissues were copiously irrigated and debrided.", + "Intraoperatively, a mid-substance, complete intramuscular biceps tear was noted.", + "The radial nerve was identified to be contused where it passed beyond the fracture site posteriorly.", + "The radial nerve was in full continuity throughout the course of the nerve.", + "The fracture was reduced and stabilized with a 4.5 mm narrow large fragment plate.", + "Attention was directed at open repair of the intramuscular, mid-substance biceps rupture.", + "Proximal and distal ends were identified.", + "Ethibond sutures were used in a running Krackow fashion.", + "The elbow was held in hyperflexion.", + "All six sutures were tied with the proximal corresponding limb repaired to the distal corresponding limb.", + "Once all six suture tails had been fully tensioned and tightened, the elbow was taken through a gentle range of motion.", + "Wound closure ensued.", + "A splint was placed in 100 degrees of flexion.", + "Postoperatively, the patient was extubated.", + "The patient was observed to be distally neurovascularly intact in radial, ulnar, and median nerve distributions.", + "Nine days after the index surgery, the patient presented due to purulent drainage from the surgical wound.", + "He was taken to the operating room for wound exploration and irrigation and debridement.", + "Intraoperatively, it was noted that the biceps repair had failed.", + "Deep tissue samples were sent for culture.", + "The area was debrided, leaving a large soft tissue defect.", + "A wound vac was then placed.", + "He was placed on antibiotics postoperatively.", + "Antibiotics were narrowed to ciprofloxacin once cultures speciated to Enterobacter and Citrobacter.", + "He was taken back to the operating room three days afterwards for a repeat wound exploration.", + "He was taken back to the operating room for repeat irrigation and debridement.", + "He was taken back to the operating room for revision open biceps repair.", + "He was treated with oral ciprofloxacin per the pediatric infectious disease recommendations.", + "He was made platform weight-bearing to the left upper extremity in a splint with a lateral side strut.", + "The arm was flexed to 100 degrees to protect the intact brachialis muscle.", + "At twelve days postoperatively, his wound was healing appropriately.", + "At his first postoperative visit 2.5 weeks after his first surgery, the surgical incision was healing well.", + "At seven weeks after his first surgery, plain film radiographs showed fracture healing.", + "There were no hardware complications.", + "His weight bearing status was advanced to weight bearing as tolerated for activities for daily living.", + "He began gentle active and passive range of motion exercises.", + "Occupational therapy for static dynamic extension splinting was initiated.", + "At 14 weeks after his first surgery, he was able to actively range his left elbow from full flexion to 10 degrees shy of full extension.", + "He had full pronation and supination.", + "His weight bearing status was advanced to weight bearing as tolerated, except for heavy lifting.", + "He completed five total months of oral antibiotic therapy with ciprofloxacin.", + "He was advanced to full weight bearing with no restrictions nine months after his index surgery.", + "At this clinical visit, he lacked two degrees of terminal extension.", + "At his most recent clinic visit one year after his index surgery, he had full flexion/extension to the left elbow.", + "He had 5/5 biceps, supination, and pronation strength.", + "He was playing sports without limitation." + ], + "summary": "A 13-year-old male presented with an open left humeral shaft fracture with intramuscular distal biceps rupture after being struck by a car. He underwent washout, humerus fixation, and open biceps repair. Immediate postoperative course was complicated by deep infection and failure of biceps repair. He subsequently required two additional surgeries. One year later, he exhibited full, painless elbow range of motion and biceps strength.", + "summary_subclaims": [ + "The patient is a 13-year-old male.", + "He had an open left humeral shaft fracture.", + "He had an intramuscular distal biceps rupture.", + "The injury occurred after being struck by a car.", + "He underwent washout.", + "He underwent humerus fixation.", + "He underwent open biceps repair.", + "The immediate postoperative course was complicated by deep infection.", + "The immediate postoperative course was complicated by failure of biceps repair.", + "He required two additional surgeries.", + "One year later, he exhibited full, painless elbow range of motion.", + "One year later, he exhibited biceps strength." + ] + }, + { + "id": "multiclinsum_test_527_en.txt", + "fulltext": "We report a case of a 51 years-old woman with medical relevant story of ductal breast carcinoma, submitted to mastectomy followed by adjuvant radio and chemotherapy. She had remained disease-free for 7 years following treatment. After this period, due to tumor recurrence, the patient was started on hormonotherapy with Fulvestrant (estrogen receptor antagonist). Three days later, she developed asthenia, anorexia, nausea and vomiting. On day 10 of therapy she was admitted in the emergency department with jaundice, dark urine and pale stools. There was no history of alcohol, drugs or natural products consumption. The patient also denied recent travels. On admission, she was hemodynamically stable and with no fever, abdominal pain or pruritus. Physical examination was positive only for icteric sclera. No other relevant findings including hepatosplenomegaly, ascites or hepatic encephalopathy were found. Also, there were no lymphadenopathies or rash. Blood tests revealed leukopenia of 3.1 × 109 (4.0-11.0 × 109) with normal eosinophil value and thrombocytopenia of 82.000 (150.000-450.000). Immunoglobulin IgE level was normal. Liver tests demonstrated a cytocholestase pattern, with elevated aminotransferases: AST 3170 IU/L (<34 IU/L), ALT 908 IU/L (<49 IU/L), GGT 1132 IU/L (<38 IU/L), alkaline phosphatase (AP) 109 IU/L (<104 IU/L), TB 5.1 mg/dl (<1.0 mg/dl) and DB 4.46 mg/dl (<0.2 mg/dl), as well as prolonged prothrombin time: 20s. (<11,6 s.) and APTT 53 s. (< 31 s.) Abdominal ultrasound showed a homogeneous liver, with regular borders. Only steatosis was evident and no nodular or mass lesions were observed.\nAn extensive workup diagnosis including chest CT, viral serologies (HAV, HBV, HCV, CMV), and autoimmune and metabolic studies failed to show an etiology for the disease. A presumptive diagnosis of liver toxicity to Fulvestrant was assumed. Although the drug was immediately withdrawn, clinical worsening occurred with the development of hepatic encephalopathy and rapid progression of acute liver failure (factor V 35%, AST 5530 IU/L, ALT 1810 IU/L, TB 8.6 mg/dl, APTT 55 s. and PT 23.4 s.) associated with bleeding diathesis. Because the patient had an active tumor recurrence which is a contraindication for liver transplant and chemotherapy wasn’t possible because of severe abnormal liver function, a transjugular liver biopsy wasn’t considered as it wouldn’t change the management of the patient. There was no response to medical support treatment and the patient died. Post-mortem examination revealed a wide hepatic infiltration by neoplastic tissue with morphologic characteristics compatible with adenocarcinoma . The carcinoma cells were arranged singly in small clusters with a high proliferation index . Immunohistochemical stains were positive for estrogens receptor but negative for progesterone and Herb2 receptors , consistent with the diagnosis of primary breast carcinoma. Unfortunately, E-cadherin and CD44 stains weren’t tested.", + "fulltext_subclaims": [ + "The patient was a 51 years-old woman.", + "The patient had a medical relevant story of ductal breast carcinoma.", + "The patient was submitted to mastectomy.", + "The patient was submitted to adjuvant radio and chemotherapy.", + "The patient had remained disease-free for 7 years following treatment.", + "The patient was started on hormonotherapy with Fulvestrant.", + "Three days after starting Fulvestrant, the patient developed asthenia.", + "Three days after starting Fulvestrant, the patient developed anorexia.", + "Three days after starting Fulvestrant, the patient developed nausea.", + "Three days after starting Fulvestrant, the patient developed vomiting.", + "On day 10 of therapy, the patient was admitted in the emergency department with jaundice.", + "On day 10 of therapy, the patient was admitted in the emergency department with dark urine.", + "On day 10 of therapy, the patient was admitted in the emergency department with pale stools.", + "There was no history of alcohol, drugs or natural products consumption.", + "The patient denied recent travels.", + "On admission, the patient was hemodynamically stable.", + "On admission, the patient had no fever.", + "On admission, the patient had no abdominal pain.", + "On admission, the patient had no pruritus.", + "Physical examination was positive for icteric sclera.", + "Blood tests revealed leukopenia of 3.1 × 109.", + "Blood tests revealed thrombocytopenia of 82.000.", + "Liver tests demonstrated a cytocholestase pattern.", + "AST was 3170 IU/L.", + "ALT was 908 IU/L.", + "GGT was 1132 IU/L.", + "TB was 5.1 mg/dl.", + "DB was 4.46 mg/dl.", + "Prothrombin time was 20s.", + "APTT was 53 s.", + "Abdominal ultrasound showed a homogeneous liver.", + "An extensive workup diagnosis failed to show an etiology for the disease.", + "A presumptive diagnosis of liver toxicity to Fulvestrant was assumed.", + "The drug was immediately withdrawn.", + "Clinical worsening occurred with the development of hepatic encephalopathy.", + "The patient had an active tumor recurrence.", + "The patient had a transjugular liver biopsy not considered.", + "The patient died.", + "Post-mortem examination revealed a wide hepatic infiltration by neoplastic tissue.", + "The neoplastic tissue had morphologic characteristics compatible with adenocarcinoma.", + "The carcinoma cells were arranged singly in small clusters.", + "The carcinoma cells had a high proliferation index.", + "Immunohistochemical stains were positive for estrogens receptor.", + "Immunohistochemical stains were negative for progesterone.", + "Immunohistochemical stains were negative for Herb2 receptors.", + "The diagnosis was consistent with primary breast carcinoma.", + "E-cadherin and CD44 stains weren’t tested." + ], + "summary": "We present a 51-years-old woman with relevant clinical history for breast cancer. The patient was admitted in the emergency department with jaundice, dark urine and pale stools. She was on the 10th day of hormonotherapy for recurrence of breast cancer, diagnosed 7 years previously. Usual causes of acute liver failure were excluded, all drugs were stopped and the imaging studies performed were positive only for steatosis. Nonetheless, ALF progressed and the patient died 4 days later. Autopsy demonstrated a massive intrasinusoidal infiltration of the liver by breast cancer cells.", + "summary_subclaims": [ + "The patient was a 51-years-old woman.", + "The patient had a relevant clinical history for breast cancer.", + "The patient was admitted in the emergency department with jaundice, dark urine and pale stools.", + "The patient was on the 10th day of hormonotherapy for recurrence of breast cancer.", + "The recurrence of breast cancer was diagnosed 7 years previously.", + "Usual causes of acute liver failure were excluded.", + "All drugs were stopped.", + "The imaging studies performed were positive only for steatosis.", + "Acute liver failure progressed.", + "The patient died 4 days after admission.", + "Autopsy demonstrated a massive intrasinusoidal infiltration of the liver by breast cancer cells." + ] + }, + { + "id": "multiclinsum_test_1570_en.txt", + "fulltext": "The proband of this family is a 5-year-old boy from Zhejiang province in China. He developed thickening nails and oral leukokeratosis at birth , and began developing palmoplantar keratoderma at 2 years old. His sister had similar clinical manifestation characterized with thickening nail and discoloration . No abnormalities in the teeth and eyes were noted in the two affected children. There were no unaffected siblings, And the phenotypic features of PC were not found in any other family members including their parents.\nAfter informed consent, genomic DNA was extracted from the peripheral blood lymphocytes of this family. DNA was also extracted from hair bulbs, buccal smears and sperm cells of the proband’s father and hair bulbs and buccal smears of his mother using a QIAGEN QIAamp Blood Mini kit. This study was approved by the Ethics Committees of Shanghai Jiaotong University School of Medicine and conducted in accordance with the principles of the Declaration of Helsinki.\nKRT6A, KRT6B, KRT6C, KRT16 and KRT17 genes of this family were analyzed by direct sequencing using primers and reaction conditions as previously described. In addition, samples from 100 unrelated population-matched controls were sequenced to exclude the possibility that the variant was a polymorphism in the KRT6A gene (GenBank accession number: NM_005554.3).\nThe exome capture were performed using Agilent SureSelect Human All Exon Kits (Agilent, Santa Clara, CA) according to the manufacturer’s instructions. Sequencing was performed on a HiSeq 2000 platform with read lengths of 100 bp. The mean coverage depth for each sample is 100 × . The sequencing reads were described according to NCBI human reference sequence.\nThe entire coding and flanking intronic sequences of KRT6A, KRT6B, KRT6C, KRT16 and KRT17 genes were screened for mutations in the two affected children and unaffected parents. A previously reported heterozygous mutation, p.Ile462Asn, was identified in KRT6A in the proband and his sister . This change was not detected in 100 unrelated, healthy Chinese control individuals (200 alleles). Sequence analysis of the four other keratin genes failed to detect sequence variants in either affected or unaffected individuals of the family . This mutation was not identified in the parents, in DNA derived from peripheral blood, hair bulbs or buccal smears . The sperm cells from proband’s father were also wildtype . Since the two affected children harbored the same pathogenic mutation, we postulated that one of the parents was mosaic for this variant WES was performed on the two affected children and their parents. Approximately 5 billion bases were sequenced with coverage of 100 × . Consequently, the variant was detected in one sequencing read from 86 sequencing reads from DNA derived from the mother’s blood . The mutation was not identified in DNA derived from the father’s blood by whole exome sequencing. The frequency of reads was 47% and 49% in proband and his sister, respectively. The results indicated that the mutation in KRT6A may be from maternal mosaicism in this family.\nTo confirm the question of somatic mosaicism in the mother, the analysis was performed to quantify the proportion of cells carrying the KRT6A mutation by using SNaPshot (ABI Prism SNaPShot multiplex kit; Applied Biosystems) on an ABI PRISM 3730 genetic analyser according to the manufacturer’s instructions. The proportion of normal and mutant DNA was quantified using GeneMapper software (v4.0; Applied Biosystems). To get mutation ratios of 50%, 25%, 12.5%, 6.25%, 3.13%, and 1.56%, a genomic DNA sample of a heterozygous proband was serially diluted with a sample of a wild-type family member. All experiments were repeated three times.\nSNaPshot analysis revealed substantial mutation-level variation in the two affected children and their parents. SNaPshot sequencing revealed mosaicism at level of 2.5% and 4.7% in DNA from the mother’s blood and hair bulbs . No mosaicism was identified in DNA from buccal smears from mother. A non-mosaic wild-type state was found in the healthy father (Data not shown).\nBesides, we also performed HiSeq deep sequencing. Firstly, We diluted the DNA from the patient’s blood with the DNA from the normal by 1/2, 1/4, 1/8, 1/16, 1/32, 1/64, 1/128 based on gradient dilution method. Making a standard curve. Then, We designed primer detection mutation site KRT6A (NM_005554.3) c.1385T > A; p.Ile462Asn. (F:TTCCTCTTCCAGTGCGCCAA; R:AGCTGTTGAAGGAGKT CGTGT) And synthesizing fusion primer. (F1:ACACGACGCTCTTCCGATCTT TCCTCTTCCAGTGCGCCAA; R1:TTCCTTGGCACCCGAGAATTCCAAGCTG TTGAAGGAGKTCGTGT) Next step, We carried out the first round PCR. (3min96°C; 15 cycles of 30 s 96 °C; 30 s 60 °C; 30 s 72 °C. End with 5 min incubation at 72 °C; pause at 10 °C.) And the second round were carried out after screened and purified. (NNNNNN was used to distinguish between different samples. F2:AATGATACGGCGACCACCGAGATCTACACTCTTTCCCTACA CGACGCTCTTCCGATCT; R2-x:CAAGCAGAAGACGGCATACGAGATNNN NNNGTGACTGGAGTTCCTTGGCAC CCGAGAAT) (3min96°C; 10 cycles of 15 s 96 °C; 30 s 60 °C; 30 s 72 °C. End with 5 min incubation at 72 °C; pause at 10 °C.) In the end, Sequencing the PCR products from last step after purified by Illumina Hiseq. And analyzing the number of T and A at the site to be tested in the total read length of each sample.\nWe sequencing the DNA sample from patient’s younger sister and parents in the same method. Calculating by Y = 1.0007x − 0.0036 as Table .", + "fulltext_subclaims": [ + "The proband is a 5-year-old boy from Zhejiang province in China.", + "The proband developed thickening nails and oral leukokeratosis at birth.", + "The proband began developing palmoplantar keratoderma at 2 years old.", + "The proband’s sister had similar clinical manifestations characterized with thickening nail and discoloration.", + "No abnormalities in the teeth and eyes were noted in the two affected children.", + "There were no unaffected siblings.", + "The phenotypic features of PC were not found in any other family members including their parents.", + "Genomic DNA was extracted from the peripheral blood lymphocytes of this family.", + "DNA was also extracted from hair bulbs, buccal smears and sperm cells of the proband’s father.", + "DNA was also extracted from hair bulbs and buccal smears of the proband’s mother.", + "This study was approved by the Ethics Committees of Shanghai Jiaotong University School of Medicine.", + "The study was conducted in accordance with the principles of the Declaration of Helsinki.", + "KRT6A, KRT6B, KRT6C, KRT16 and KRT17 genes of this family were analyzed by direct sequencing.", + "Samples from 100 unrelated population-matched controls were sequenced to exclude the possibility that the variant was a polymorphism in the KRT6A gene.", + "Exome capture was performed using Agilent SureSelect Human All Exon Kits.", + "Sequencing was performed on a HiSeq 2000 platform with read lengths of 100 bp.", + "The mean coverage depth for each sample is 100 × .", + "The sequencing reads were described according to NCBI human reference sequence.", + "The entire coding and flanking intronic sequences of KRT6A, KRT6B, KRT6C, KRT16 and KRT17 genes were screened for mutations in the two affected children and unaffected parents.", + "A previously reported heterozygous mutation, p.Ile462Asn, was identified in KRT6A in the proband and his sister.", + "This change was not detected in 100 unrelated, healthy Chinese control individuals (200 alleles).", + "Sequence analysis of the four other keratin genes failed to detect sequence variants in either affected or unaffected individuals of the family.", + "This mutation was not identified in the parents, in DNA derived from peripheral blood, hair bulbs or buccal smears.", + "The sperm cells from proband’s father were also wildtype.", + "Since the two affected children harbored the same pathogenic mutation, we postulated that one of the parents was mosaic for this variant.", + "WES was performed on the two affected children and their parents.", + "Approximately 5 billion bases were sequenced with coverage of 100 × .", + "The variant was detected in one sequencing read from 86 sequencing reads from DNA derived from the mother’s blood.", + "The mutation was not identified in DNA derived from the father’s blood by whole exome sequencing.", + "The frequency of reads was 47% and 49% in proband and his sister, respectively.", + "The results indicated that the mutation in KRT6A may be from maternal mosaicism in this family.", + "To confirm the question of somatic mosaicism in the mother, the analysis was performed to quantify the proportion of cells carrying the KRT6A mutation by using SNaPshot.", + "SNaPshot analysis revealed substantial mutation-level variation in the two affected children and their parents.", + "SNaPshot sequencing revealed mosaicism at level of 2.5% and 4.7% in DNA from the mother’s blood and hair bulbs.", + "No mosaicism was identified in DNA from buccal smears from mother.", + "A non-mosaic wild-type state was found in the healthy father.", + "We also performed HiSeq deep sequencing.", + "We diluted the DNA from the patient’s blood with the DNA from the normal by 1/2, 1/4, 1/8, 1/16, 1/32, 1/64, 1/128 based on gradient dilution method.", + "We designed primer detection mutation site KRT6A (NM_005554.3) c.1385T > A; p.Ile462Asn.", + "We carried out the first round PCR.", + "We carried out the second round after screened and purified.", + "We sequencing the DNA sample from patient’s younger sister and parents in the same method.", + "We calculated by Y = 1.0007x − 0.0036 as Table ." + ], + "summary": "We report the case of a 5-year-old boy with thickening nails and oral leukokeratosis at birth. He began to develop palmoplantar keratoderma at 2 years old and his sister has similar clinical manifestation characterized with nail discoloration and thickening. A previously reported heterozygous mutation, p.Ile462Asn, was identified in KRT6A in the proband and his affected sister. SNaPshot sequencing revealed mosaicism at a level of 2.5% and 4.7% in DNA from blood and hair bulbs from the unaffected mother. HiSeq deep sequencing demonstrated low-grade mosaicism in the patient's younger sister and parents.", + "summary_subclaims": [ + "The patient is a 5-year-old boy.", + "The patient had thickening nails and oral leukokeratosis at birth.", + "The patient began to develop palmoplantar keratoderma at 2 years old.", + "The patient's sister has similar clinical manifestations.", + "The patient's sister has nail discoloration and thickening.", + "A previously reported heterozygous mutation, p.Ile462Asn, was identified in KRT6A in the proband.", + "A previously reported heterozygous mutation, p.Ile462Asn, was identified in KRT6A in the affected sister.", + "SNaPshot sequencing revealed mosaicism at a level of 2.5% in DNA from blood from the unaffected mother.", + "SNaPshot sequencing revealed mosaicism at a level of 4.7% in DNA from hair bulbs from the unaffected mother.", + "HiSeq deep sequencing demonstrated low-grade mosaicism in the patient's younger sister.", + "HiSeq deep sequencing demonstrated low-grade mosaicism in the parents." + ] + }, + { + "id": "multiclinsum_test_1009_en.txt", + "fulltext": "We report the case of a 29-year-old male patient (smoker) not known to have any medical illnesses. He presented to our outpatient clinic at King Abdullah University Hospital, Jordan, complaining of a painless mass in the right breast of 2 weeks duration. The patient denied any history of trauma. The systemic review and family history were unremarkable. The examination revealed a retroareolar painless lump in the right breast at 2 o'clock, about 1 × 1 cm in diameter, not associated with skin changes or regional lymphadenopathy. Contralateral breast and axillary lymph nodes were unremarkable.\nBreast ultrasound showed a hypoechoic soft tissue lesion measuring about 5 × 2 mm with increased vascularity. Laboratory tests including complete blood count and blood chemistry were within normal ranges.\nAn excisional biopsy with margin through a periareolar skin incision was performed. Histopathology revealed a 1.3 × 1 × 0.4-cm mass, with clusters of inflammatory cells including lymphocytes, neutrophils, epithelioid histiocytes and giant cells surrounding a cyst-like lesion lined by squamous cells, consistent with GM .\nThe tissue was cultured, and special stains were used. No microorganisms were identified. There was no evidence of malignancy. Patient follow-up at 3 months did not show any evidence of recurrence.", + "fulltext_subclaims": [ + "The patient is a 29-year-old male.", + "The patient is a smoker.", + "The patient presented with a painless mass in the right breast.", + "The mass had been present for 2 weeks.", + "The patient denied any history of trauma.", + "The systemic review was unremarkable.", + "The family history was unremarkable.", + "The examination revealed a retroareolar painless lump in the right breast at 2 o'clock.", + "The lump was about 1 × 1 cm in diameter.", + "There were no skin changes associated with the lump.", + "There was no regional lymphadenopathy.", + "Contralateral breast and axillary lymph nodes were unremarkable.", + "Breast ultrasound showed a hypoechoic soft tissue lesion measuring about 5 × 2 mm.", + "The lesion had increased vascularity.", + "Laboratory tests including complete blood count and blood chemistry were within normal ranges.", + "An excisional biopsy with margin was performed through a periareolar skin incision.", + "Histopathology revealed a 1.3 × 1 × 0.4-cm mass.", + "The mass contained clusters of inflammatory cells including lymphocytes, neutrophils, epithelioid histiocytes, and giant cells.", + "The mass surrounded a cyst-like lesion lined by squamous cells.", + "The histopathology findings were consistent with granulomatous mastitis.", + "The tissue was cultured.", + "Special stains were used.", + "No microorganisms were identified.", + "There was no evidence of malignancy.", + "Patient follow-up at 3 months did not show any evidence of recurrence." + ], + "summary": "A 29-year-old male patient presented with a hard, painless lump in the right breast of 2 weeks duration. The patient underwent surgical excision with margin. The histopathologic findings were consistent with granulomatous mastitis. The case was reported as idiopathic granulomatous mastitis after exclusion of all known causes of the disease.", + "summary_subclaims": [ + "A 29-year-old male patient presented with a hard, painless lump in the right breast of 2 weeks duration.", + "The patient underwent surgical excision with margin.", + "The histopathologic findings were consistent with granulomatous mastitis.", + "The case was reported as idiopathic granulomatous mastitis after exclusion of all known causes of the disease." + ] + }, + { + "id": "multiclinsum_test_1699_en.txt", + "fulltext": "A woman in her early 20s presented initially with cervical and thoracic back pain and left-sided numbness, during the second trimester of pregnancy, in April/2011. A week later, she had paraplegia that progressed to tetraplegia and bladder/bowel incontinence. At the nadir, 2 weeks after onset, she was wheelchair dependent. A cerebrospinal fluid (CSF) study revealed 10 cells/mm3 (49.5% lymphocytes, 47.5% neutrophils, 2% monocytes, and 1% eosinophils), protein of 42 mg/dL (normal, 0 to 45 mg/dL), and negative oligoclonal bands (OCBs). Serum cell-based assay AQP4-IgG was positive. She was treated with a 5-day course of intravenous methylprednisolone (IVMP) 1 g daily with some improvement in her upper limbs paresis. In July/2011, the patient had a severe bilateral optic neuritis relapse. In October/2011, she had worsening upper limbs' paresis, which repeated on July/13 and December/14, reaching an expanded disability status scale (EDSS) of 8.0. Cervical spine MRI showed a focal enhancing lesion at the C2-3 level and spinal cord atrophy (–). In August/2013, she started to attend our outpatient clinic and was diagnosed with NMOSD, and commenced azathioprine (2.5 mg/kg/d) until August/2016, when she presented severe macrocytic anemia. At this time, the treatment was switched to the chimeric anti-CD20 monoclonal antibody (mAb) (rituximab). In November/2017, she presented a persistent EDSS of 8.0 and agreed to participate in our study. Similarly to the protocol mentioned , a blood sample was collected, and peripheral blood mononuclear cells (PBMCs) were obtained to investigate cytotoxic-related functions in circulating T- and B- cells using flow cytometry analyses. In March/2019, the patient died due to pulmonary thromboembolism (PTE) and lower extremity deep vein thrombosis (DVT) (clinical history is summarized in ).", + "fulltext_subclaims": [ + "A woman in her early 20s presented initially with cervical and thoracic back pain and left-sided numbness, during the second trimester of pregnancy, in April/2011.", + "A week later, she had paraplegia that progressed to tetraplegia and bladder/bowel incontinence.", + "At the nadir, 2 weeks after onset, she was wheelchair dependent.", + "A cerebrospinal fluid (CSF) study revealed 10 cells/mm3 (49.5% lymphocytes, 47.5% neutrophils, 2% monocytes, and 1% eosinophils).", + "Serum cell-based assay AQP4-IgG was positive.", + "She was treated with a 5-day course of intravenous methylprednisolone (IVMP) 1 g daily with some improvement in her upper limbs paresis.", + "In July/2011, the patient had a severe bilateral optic neuritis relapse.", + "In October/2011, she had worsening upper limbs' paresis.", + "Cervical spine MRI showed a focal enhancing lesion at the C2-3 level and spinal cord atrophy.", + "In August/2013, she started to attend our outpatient clinic and was diagnosed with NMOSD.", + "She was commenced on azathioprine (2.5 mg/kg/d) until August/2016, when she presented severe macrocytic anemia.", + "At this time, the treatment was switched to the chimeric anti-CD20 monoclonal antibody (mAb) (rituximab).", + "In November/2017, she presented a persistent EDSS of 8.0.", + "A blood sample was collected, and peripheral blood mononuclear cells (PBMCs) were obtained to investigate cytotoxic-related functions in circulating T- and B- cells using flow cytometry analyses.", + "In March/2019, the patient died due to pulmonary thromboembolism (PTE) and lower extremity deep vein thrombosis (DVT)." + ], + "summary": "Here, we describe an Aquaporin-4 positive (AQP4-positive) NMOSD patient who showed short myelitis (SM) and experienced a fatal pulmonary thromboembolism/lower extremity deep vein thrombosis during anti-CD20 treatment. Flow cytometry analyses from the peripheral blood revealed an enhanced cytotoxic behavior through circulating CD8+GzmB+ T, CD4+GzmB+ T lymphocytes, and residual CD19+GzmB+ B cells.", + "summary_subclaims": [ + "The patient was Aquaporin-4 positive.", + "The patient had short myelitis.", + "The patient experienced a fatal pulmonary thromboembolism.", + "The patient had lower extremity deep vein thrombosis.", + "The patient was undergoing anti-CD20 treatment.", + "Flow cytometry analyses were performed on peripheral blood.", + "Circulating CD8+GzmB+ T lymphocytes showed enhanced cytotoxic behavior.", + "Circulating CD4+GzmB+ T lymphocytes showed enhanced cytotoxic behavior.", + "Residual CD19+GzmB+ B cells were detected." + ] + }, + { + "id": "multiclinsum_test_44_en.txt", + "fulltext": "A 13-year old male presented to an ED with complaints of “frequent eye blinking” and reoccurring episodes of “stiffening and abnormal movements of the hands and neck” and “flickering of the upper lips” that began 24 hours prior to his arrival. About one week prior to presenting at the ED, the patient had been discharged from a psychiatric hospital, and his discharge medications for his mood disorder (Mood Disorder Not Otherwise Specified) included quetiapine 500 milligrams (mg) by mouth (PO) daily (qd) and valproic acid (VPA) 500 mg PO at bedtime (qhs). His dosing regimen of quetiapine for the three months before that hospitalization had been 100 mg qd, and he had not previously been prescribed VPA.\nThe patient reported having insufflated two crushed tablets of quetaipine 500 mg on four separate occasions in the previous forty-eight hours. His desire to experience euphoria motivated him to abuse his prescription quetiapine. He reported having not taken his prescribed VPA in three days and also reported that he had not recently used any other medications, supplements, or illicit drugs. His symptoms began two hours after the last insufflation of quetiapine, the episodes of excessive eye-blinking and lip-flickering were intermittent, and the twitching of his eyelids was continuous.\nAt the time of presentation, the patient was fully alert and had a Glascow Coma Scale of 15. He was afebrile, tachycardic (115 beats/minute), tachypnic (18 respirations/minute), and had normal oxygen saturation without supplemental oxygen. Physical exam abnormalities included only active twitching of both upper eyelids and bilateral dilated pupils (4/5). During observation in the emergency department, the patient had two myoclonic episodes of the extremities and intense flickering of the eyelids that the patient reported were associated with him turning his head to the right. The episodes lasted about two minutes, and the patient was alert and oriented during the episodes. The patient reported feeling restless and had a constant desire to walk. Results from a 10-panel urine toxicology screen performed at admission were negative for common drugs of abuse, and lorazepam 1.5 mg intravenous (IV) was given to relax the patient. His restlessness worsened, however, and he was admitted for observation and treatment of neuroleptic toxicity. Diphenhydramine 50 mg IV was administered, and he was in stable condition within 24 hours. Quetiapine was discontinued, and the patient was discharged and referred for substance abuse evaluation and treatment. His primary care provider and psychiatrist were notified regarding the medication abuse.", + "fulltext_subclaims": [ + "The patient is a 13-year old male.", + "The patient presented to an ED with complaints of 'frequent eye blinking'.", + "The patient reported reoccurring episodes of 'stiffening and abnormal movements of the hands and neck'.", + "The patient reported 'flickering of the upper lips'.", + "The symptoms began 24 hours prior to his arrival.", + "The patient had been discharged from a psychiatric hospital about one week prior to presenting at the ED.", + "His discharge medications included quetiapine 500 mg PO daily.", + "His discharge medications included valproic acid (VPA) 500 mg PO at bedtime.", + "His mood disorder was diagnosed as Mood Disorder Not Otherwise Specified.", + "His dosing regimen of quetiapine for the three months before hospitalization had been 100 mg qd.", + "He had not previously been prescribed VPA.", + "The patient reported having insufflated two crushed tablets of quetiapine 500 mg on four separate occasions in the previous forty-eight hours.", + "His desire to experience euphoria motivated him to abuse his prescription quetiapine.", + "He reported having not taken his prescribed VPA in three days.", + "He reported that he had not recently used any other medications, supplements, or illicit drugs.", + "His symptoms began two hours after the last insufflation of quetiapine.", + "The episodes of excessive eye-blinking and lip-flickering were intermittent.", + "The twitching of his eyelids was continuous.", + "At the time of presentation, the patient was fully alert.", + "He had a Glascow Coma Scale of 15.", + "He was afebrile.", + "He was tachycardic (115 beats/minute).", + "He was tachypnic (18 respirations/minute).", + "He had normal oxygen saturation without supplemental oxygen.", + "Physical exam abnormalities included active twitching of both upper eyelids.", + "Physical exam abnormalities included bilateral dilated pupils (4/5).", + "During observation in the emergency department, the patient had two myoclonic episodes of the extremities.", + "The patient reported feeling restless.", + "He had a constant desire to walk.", + "Results from a 10-panel urine toxicology screen performed at admission were negative for common drugs of abuse.", + "Lorazepam 1.5 mg IV was given to relax the patient.", + "His restlessness worsened.", + "He was admitted for observation and treatment of neuroleptic toxicity.", + "Diphenhydramine 50 mg IV was administered.", + "He was in stable condition within 24 hours.", + "Quetiapine was discontinued.", + "The patient was discharged and referred for substance abuse evaluation and treatment.", + "His primary care provider and psychiatrist were notified regarding the medication abuse." + ], + "summary": "We describe the case of a 13-year-old male who presented to an emergency department with acute movement disorders after nasal insufflation of crushed quetiapine. The patient was admitted and successfully treated for neuroleptic toxicity with intravenous antihistamine pharmacotherapy. His primary care provider and psychiatrist were notified of the abuse, quetiapine was discontinued, and the patient was discharged and referred to a drug and alcohol awareness and abuse program.", + "summary_subclaims": [ + "The patient was a 13-year-old male.", + "The patient presented to an emergency department with acute movement disorders.", + "The acute movement disorders occurred after nasal insufflation of crushed quetiapine.", + "The patient was admitted and successfully treated for neuroleptic toxicity.", + "Intravenous antihistamine pharmacotherapy was used.", + "The patient's primary care provider and psychiatrist were notified of the abuse.", + "Quetiapine was discontinued.", + "The patient was discharged.", + "The patient was referred to a drug and alcohol awareness and abuse program." + ] + }, + { + "id": "multiclinsum_test_3289_en.txt", + "fulltext": "31-year-old female patient (C.) referred to the rehabilitation center after suffering an ischemic stroke with hemorrhagic transformation, the result of an aneurysm in the right middle cerebral artery. She was admitted to the institution with a month of evolution of the brain damage and was referred to the occupational therapy service.\n\nThe Functional Independence Measure (FIM) was administered during the initial evaluation to assess the level of assistance required in basic activities of daily living (ADL). The patient was fed by nasogastric tube, required maximum assistance in minor grooming and communication. She also received full assistance in dressing, bathing, using the toilet, transfers, functional mobility and continence.\n\nFrom the observation of occupational performance, alterations in motor skills related to obtaining and holding objects, the position of the body in relation to space and objects and maintaining execution were detected. An important apraxic component of movement was observed, which impacted the functional use of objects in daily tasks, so the Tulia Apraxia Test (AST) was administered, which rated the performance as severe apraxia. C. retained the processing skills related to the ability to keep up with an activity and the temporal organization of the same; not so the skills related to the organization of space and objects. As for the social interaction skills, she managed to look at the interlocutor and respond to their questions, although she was not able to initiate or end a conversation, produce language, keep up with the interaction or verbally support it. According to the evaluation of the speech therapy service, the patient had global aphasia.\n\nC. participated in an interdisciplinary treatment (TO, kinesiology, phonoaudiology, music therapy, cognitive rehabilitation) and intensive (5 hours daily of therapy, specifically 1 hour of TO) in an inpatient setting.\n\nIn line with the reported baseline level, the objectives were defined together with the patient: (1) That the patient can increase her collaboration in basic ADLs, gradually decreasing the assistance required. (2) That the patient can incorporate her right upper limb (MSD) in functional activities. (3) That the patient can participate in instrumental ADLs with supervision.\n\nC. was admitted to the rehabilitation center for 5 months. The intervention from OT during the first month of admission focused on training in strategies to increase participation in basic ADLs, indicating the family the corresponding level of assistance. Due to the subluxation presented, she entered an 8-week protocol in which the use of rigid shoulder bandage and functional electrical stimulation in the shoulder musculature is combined, which is carried out together with kinesiology.\n\nIntervention during the second month focused on increasing motor and processing skills to continue training in basic ADL. Thickened handles were made for cutlery, which helped to hold them, and the bathroom environment was modified to facilitate the reach of the toiletries. We also worked together with a speech therapist to train the patient in accessing an augmentative alternative communication (AAC) application on her cell phone and the functional use of it.\n\nDuring the third month, sensory-motor reeducation of the MSD was performed to favor its incorporation into the ADLs. The protocol of movement therapy induced by restriction of the healthy limb was performed for 14 consecutive days. The Motor Activity Log (MAL) evaluation was administered in order to have an objective assessment of the use of the affected upper limb in daily activities before and after the protocol.\n\nDuring the fourth month, the treatment focused on increasing C.'s processing skills during instrumental ADL participation. Temporal, spatial and object organization were worked on in activities such as food preparation and handling of desk tools, and the spontaneous incorporation of the MSD in these activities.\n\nIn the final evaluation, the patient was able to increase her level of independence in all basic ADLs, requiring more time in the activities of minor grooming, bathing, dressing, use of the toilet and social interaction. In terms of communication, C. was able to understand abstract ideas and complex conversations with minimal difficulty and was able to express herself orally, relying on the use of the CAA application. In addition, she incorporated the MSD spontaneously in basic and instrumental ADLs with a slight decrease in the efficiency of movement. Finally, she was able to participate in instrumental ADLs such as household chores, shopping, and preparing food with supervision. When comparing the evaluations administered at admission and discharge, an improvement in performance in all skills was observed.\n", + "fulltext_subclaims": [ + "The patient is a 31-year-old female.", + "She suffered an ischemic stroke with hemorrhagic transformation.", + "The stroke was due to an aneurysm in the right middle cerebral artery.", + "She was admitted to the rehabilitation center with a month of evolution of the brain damage.", + "The Functional Independence Measure (FIM) was administered during the initial evaluation.", + "The patient was fed by nasogastric tube.", + "She required maximum assistance in minor grooming and communication.", + "She received full assistance in dressing, bathing, using the toilet, transfers, functional mobility and continence.", + "Alterations in motor skills related to obtaining and holding objects were detected.", + "An important apraxic component of movement was observed.", + "The Tulia Apraxia Test (AST) was administered.", + "The AST rated the performance as severe apraxia.", + "The patient retained the processing skills related to the ability to keep up with an activity.", + "The patient retained the temporal organization of an activity.", + "The patient did not retain the skills related to the organization of space and objects.", + "She managed to look at the interlocutor and respond to their questions.", + "She was not able to initiate or end a conversation.", + "She was not able to produce language.", + "She was not able to keep up with the interaction.", + "She was not able to verbally support the interaction.", + "The patient had global aphasia according to the speech therapy evaluation.", + "The patient participated in an interdisciplinary treatment.", + "The treatment included occupational therapy, kinesiology, phonoaudiology, music therapy, and cognitive rehabilitation.", + "The treatment was intensive, 5 hours daily.", + "The treatment included 1 hour of occupational therapy daily.", + "The treatment was in an inpatient setting.", + "The objectives were defined together with the patient.", + "The first objective was to increase collaboration in basic ADLs, gradually decreasing the assistance required.", + "The second objective was to incorporate the right upper limb in functional activities.", + "The third objective was to participate in instrumental ADLs with supervision.", + "The patient was admitted to the rehabilitation center for 5 months.", + "The intervention from occupational therapy during the first month focused on training in strategies to increase participation in basic ADLs.", + "The family was indicated the corresponding level of assistance.", + "She entered an 8-week protocol for subluxation.", + "The protocol combined the use of rigid shoulder bandage and functional electrical stimulation in the shoulder musculature.", + "The protocol was carried out together with kinesiology.", + "During the second month, the intervention focused on increasing motor and processing skills to continue training in basic ADL.", + "Thickened handles were made for cutlery.", + "The bathroom environment was modified to facilitate the reach of toiletries.", + "The patient was trained in accessing an augmentative alternative communication (AAC) application on her cell phone.", + "The patient was trained in the functional use of the AAC application.", + "During the third month, sensory-motor reeducation of the right upper limb was performed.", + "The protocol of movement therapy induced by restriction of the healthy limb was performed for 14 consecutive days.", + "The Motor Activity Log (MAL) evaluation was administered before and after the protocol.", + "During the fourth month, the treatment focused on increasing processing skills during instrumental ADL participation.", + "Temporal, spatial and object organization were worked on in activities such as food preparation and handling of desk tools.", + "The spontaneous incorporation of the right upper limb in these activities was worked on.", + "In the final evaluation, the patient was able to increase her level of independence in all basic ADLs.", + "She required more time in the activities of minor grooming, bathing, dressing, use of the toilet and social interaction.", + "The patient was able to understand abstract ideas and complex conversations with minimal difficulty.", + "She was able to express herself orally, relying on the use of the AAC application.", + "She incorporated the right upper limb spontaneously in basic and instrumental ADLs.", + "There was a slight decrease in the efficiency of movement.", + "She was able to participate in instrumental ADLs such as household chores, shopping, and preparing food with supervision.", + "An improvement in performance in all skills was observed when comparing the evaluations at admission and discharge." + ], + "summary": "C. is a 31-year-old adult who, after suffering an ischemic stroke, entered a rehabilitation center for patients with neurological injuries as an inpatient and received occupational therapy treatment. From this area, an approach is made from the planning and implementation of person-centered interventions, establishing short- and medium-term objectives in a collaborative manner. The effectiveness of these interventions was measured using specific evaluation tools to document the changes produced between admission and discharge from the hospital.\n", + "summary_subclaims": [ + "C. is a 31-year-old adult.", + "C. suffered an ischemic stroke.", + "C. entered a rehabilitation center for patients with neurological injuries as an inpatient.", + "C. received occupational therapy treatment.", + "An approach is made from the planning and implementation of person-centered interventions.", + "Short- and medium-term objectives are established in a collaborative manner.", + "The effectiveness of these interventions was measured using specific evaluation tools.", + "The changes produced between admission and discharge from the hospital were documented." + ] + }, + { + "id": "multiclinsum_test_66_en.txt", + "fulltext": "A 68-year-old male noticed headaches on July 8, 2012, and then right hemiparesis on July 19 of the same year. The primary care physician diagnosed stroke, and he was admitted to hospital. He had no medical history of head trauma, sinusitis, or diabetes, but he drank 1,800 mL of a distilled spirit (equivalent to 330 g of ethanol) with blue cheese every day, and had alcoholic liver cirrhosis (Child-Pugh grade B). He was febrile (39.0℃) and had become progressively paralyzed on the right side of his body. Brain magnetic resonance imaging (MRI) disclosed several ring-enhancing lesions in the brainstem and cerebral hemispheres. A cerebrospinal fluid (CSF) examination revealed pleocytosis, and a blood examination revealed an increased titer of Aspergillus antigen without inflammatory reaction; the (1→3)-β-D-glucan test was negative.\nBacterial cultures taken from two independent vessels grew L. monocytogenes, which led to a diagnosis of multiple brain abscesses due to L. monocytogenes infection. He was treated with ampicillin (ABPC; 2 g every 4 h i.v.) and voriconazole (200 mg/day), but he developed consciousness disturbance and complete right-sided hemiparesis. Follow-up brain MRI disclosed extended lesions, and the patient was transferred to our hospital. Upon admission he had a body temperature of 36.9℃, and a physical examination revealed neither superficial lymphadenopathy nor hepatosplenomegaly. A neurologic examination revealed that he was in a comatose state (score on the Japan Coma Scale of 30-200). Right blepharoptosis and anisocoria (3.0 mm on the right and 4.0 mm on the left) was observed. The left light reflex was attenuated, while that on the right was preserved. His oculocephalic reflex was positive. The right hemiparesis was severe but without muscular waste and fasciculation. The tendon reflexes were exaggerated in the right upper and lower limbs, but without pathologic reflexes. Neither neck stiffness nor Kernig's sign was detected. Laboratory data revealed no inflammatory reaction such as leukocytosis or elevation of C-reactive protein, but pleocytosis was evident in the CSF: 101 cells/mm3 (96.6% monomorphonuclear and 3.4% polymorphonuclear cells); protein, 201 mg/dL; and glucose, 58 mg/dL (plasma glucose, 78 mg/dL). No pathogenic bacteria grew in bacterial cultures of the CSF, blood, urine, and a nasopharyngeal swab.\nBrain MRI disclosed several ring-enhancing lesions on the left cerebral hemisphere and brainstem . High-intensity signals were present inside the mass lesions in diffusion-weighted imaging . Susceptibility-weighted imaging disclosed a dual rim sign, defined as two concentric rims at the lesion margins, with the outer rim being hypointense and the inner rim hyperintense relative to the cavity contents . MR spectroscopy revealed no elevation of choline in the lesions. Positron-emission tomography (PET) demonstrated no uptake of 2-[fluorine-18]-fluoro-2-deoxy-D-glucose, suggesting the absence of malignancy.\nTreatment with ABPC (2 g every 4 h i.v.) and voriconazole (100 mg every 12 h i.v.) was continued. Diagnostic and therapeutic drainage for brainstem lesions is not favored at our neurosurgical department, and so the patient instead underwent HBO therapy (100% O2 at 196.1 kPa abs at 1 h/day, for 25 days) from August 17. After the treatment, his consciousness status and pleocytosis gradually improved. The anisocoria had resolved by August 20, and voluntary movements of the right upper and lower limbs were possible by September 5 . Since the lesions were dramatically ameliorated on follow-up MRI, we terminated the voriconazole and ABPC therapy on October 3 and 10, respectively. The patient was transferred to another hospital for rehabilitation on October 17.", + "fulltext_subclaims": [ + "The patient is a 68-year-old male.", + "He noticed headaches on July 8, 2012.", + "He noticed right hemiparesis on July 19, 2012.", + "The primary care physician diagnosed stroke.", + "He had no medical history of head trauma.", + "He had no medical history of sinusitis.", + "He had no medical history of diabetes.", + "He drank 1,800 mL of a distilled spirit (equivalent to 330 g of ethanol) with blue cheese every day.", + "He had alcoholic liver cirrhosis (Child-Pugh grade B).", + "He was febrile (39.0℃).", + "He had become progressively paralyzed on the right side of his body.", + "Brain MRI disclosed several ring-enhancing lesions in the brainstem and cerebral hemispheres.", + "A CSF examination revealed pleocytosis.", + "A blood examination revealed an increased titer of Aspergillus antigen without inflammatory reaction.", + "The (1→3)-β-D-glucan test was negative.", + "Bacterial cultures taken from two independent vessels grew L. monocytogenes.", + "The diagnosis was multiple brain abscesses due to L. monocytogenes infection.", + "He was treated with ampicillin (2 g every 4 h i.v.) and voriconazole (200 mg/day).", + "He developed consciousness disturbance.", + "He had complete right-sided hemiparesis.", + "Follow-up brain MRI disclosed extended lesions.", + "The patient was transferred to our hospital.", + "Upon admission, he had a body temperature of 36.9℃.", + "A physical examination revealed neither superficial lymphadenopathy nor hepatosplenomegaly.", + "A neurologic examination revealed that he was in a comatose state (score on the Japan Coma Scale of 30-200).", + "Right blepharoptosis and anisocoria (3.0 mm on the right and 4.0 mm on the left) was observed.", + "The left light reflex was attenuated.", + "The right light reflex was preserved.", + "His oculocephalic reflex was positive.", + "The right hemiparesis was severe but without muscular waste and fasciculation.", + "The tendon reflexes were exaggerated in the right upper and lower limbs.", + "No pathologic reflexes were detected.", + "Neither neck stiffness nor Kernig's sign was detected.", + "Laboratory data revealed no inflammatory reaction such as leukocytosis or elevation of C-reactive protein.", + "Pleocytosis was evident in the CSF: 101 cells/mm3 (96.6% monomorphonuclear and 3.4% polymorphonuclear cells).", + "CSF protein was 201 mg/dL.", + "CSF glucose was 58 mg/dL (plasma glucose, 78 mg/dL).", + "No pathogenic bacteria grew in bacterial cultures of the CSF.", + "No pathogenic bacteria grew in bacterial cultures of the blood.", + "No pathogenic bacteria grew in bacterial cultures of the urine.", + "No pathogenic bacteria grew in bacterial cultures of a nasopharyngeal swab.", + "Brain MRI disclosed several ring-enhancing lesions on the left cerebral hemisphere and brainstem.", + "High-intensity signals were present inside the mass lesions in diffusion-weighted imaging.", + "Susceptibility-weighted imaging disclosed a dual rim sign, defined as two concentric rims at the lesion margins, with the outer rim being hypointense and the inner rim hyperintense relative to the cavity contents.", + "MR spectroscopy revealed no elevation of choline in the lesions.", + "PET demonstrated no uptake of 2-[fluorine-18]-fluoro-2-deoxy-D-glucose.", + "PET suggested the absence of malignancy.", + "Treatment with ABPC (2 g every 4 h i.v.) and voriconazole (100 mg every 12 h i.v.) was continued.", + "Diagnostic and therapeutic drainage for brainstem lesions is not favored at our neurosurgical department.", + "The patient underwent HBO therapy (100% O2 at 196.1 kPa abs at 1 h/day, for 25 days) from August 17.", + "After the treatment, his consciousness status and pleocytosis gradually improved.", + "The anisocoria had resolved by August 20.", + "Voluntary movements of the right upper and lower limbs were possible by September 5.", + "The lesions were dramatically ameliorated on follow-up MRI.", + "We terminated the voriconazole therapy on October 3.", + "We terminated the ABPC therapy on October 10.", + "The patient was transferred to another hospital for rehabilitation on October 17." + ], + "summary": "We report herein a patient with supra- and subtentorial brain abscesses caused by L. monocytogenes infection. These abscesses did not respond to antibiotics, and his symptoms gradually worsened. Drainage was not indicated for subtentorial lesions, and the patient was additionally treated with hyperbaric oxygen therapy, which dramatically reduced the volume of abscesses and improved the symptoms.", + "summary_subclaims": [ + "The patient had supra- and subtentorial brain abscesses caused by L. monocytogenes infection.", + "The abscesses did not respond to antibiotics.", + "The patient's symptoms gradually worsened.", + "Drainage was not indicated for subtentorial lesions.", + "The patient was additionally treated with hyperbaric oxygen therapy.", + "Hyperbaric oxygen therapy dramatically reduced the volume of abscesses.", + "Hyperbaric oxygen therapy improved the symptoms." + ] + }, + { + "id": "multiclinsum_test_940_en.txt", + "fulltext": "A 43-year-old Chinese man, who complained of shortness of breath on exertion for 7 d and a 13-year history of peripheral blood eosinophilia, was admitted to our hospital.\nThe patient was treated at a local hospital in August 2005 because routine blood examination showed a white blood cell count of 8.5 × 109/L, with 24.2% of eosinophils (2 × 109/L). In a bone marrow biopsy, eosinophils accounted for 13.5%, most with normally segmented rod nuclei. Once oral triamcinolone was initiated (4 mg, tid), the eosinophil counts rapidly normalized. After gradual dosage reduction in a span of 6 mo and eventual discontinuation, hyperplastic and nodular changes developed in both breasts, accompanied by abnormal lactation and bilateral axillary node enlargement. This condition was sufficiently burdensome to require surgery. Bilateral mastectomy was subsequently performed (January 2006) for chronic mastitis. Postoperative pathology examination disclosed male breast development and severe chronic inflammation (i.e., dilatation of mammary ducts with interstitial influx of eosinophils) .\nOne month later, the patient presented with joint pain of the trunk and limbs, movement dysfunction, and an exacerbated skin rash. Dexamethasone and prednisone were prescribed. An herbal extract (Tripterygium wilfordii) was also used shortly and then abandoned due to severe treatment-related alopecia. Thereafter, the joint symptoms gradually relented, allowing the patient to resume work. In April 2017, however, bilateral lower extremity edema developed spontaneously (blood pressure, 150/100 mmHg; plasma albumin, 15.6 g/L; low-density lipoproteins, 6.87 mmol/L; and 24-h urinary protein, 14.78 g/d), prompting a clinical diagnosis of nephrotic syndrome. A kidney biopsy was performed, establishing a pathologic diagnosis of focal segmental glomerulosclerosis, non-specific type . A second bone marrow puncture again was indicative of eosinophilia, but qualitative polymerase chain reaction failed to detect the FIP1L1-PDGFRA fusion gene. The patient was given prednisone orally at an initial dose of 60 mg (12 tablets) per day. This was gradually reduced and discontinued in March 2018, at which time all parameters of nephrotic syndrome were stable.\nOne month after medication withdrawal, hospital readmission was brought on by shortness of breath (April 2018).\nHe initially presented in December 2004 with constipation, abdominal distension, and persistent vomiting. Gastroscopic inspection revealed superficial gastritis, duodenal bulbar inflammation, and gastric retention. Enteroscopy was then performed, showing rectosigmoid mucositis. Interstitial inflammatory infiltrates were prominent in gastric and colonic mucosal biopsies. After symptomatic treatment, the digestive symptoms gradually abated and disappeared. Several months later, the patient developed an erythematous papular skin rash and vitiligo. The rash coalesced in places but was largely confined to the dorsa of hands and limbs in a symmetric distribution, without itching. Vitiligo chiefly affected the face and trunk.\nHistorically, the patient’s birth was premature (8 mo of gestation). There was one episode of pertussis during childhood and many instances of pneumonia. The patient’s father had succumbed to gastric cancer at the age of 50.\nPhysical examination revealed alopecia, loss of facial and trunk pigmentation, and an erythematous rash on the dorsa of both hands and limbs . No dry or wet rales were detected in either lung.\nPertinent laboratory results were as follows: Blood eosinophil count, 0.41 × 109/L; total IgE, 1491 IU/ml; PaO2, 53.6 mmHg; and SaO2, 91.2%. In bronchoscopic alveolar lavage fluid, eosinophils represented 30.0% of cells (CD4+/CD8+ = 0.15).\nChest computed tomography (CT) showed interstitial pneumonia .", + "fulltext_subclaims": [ + "The patient is a 43-year-old Chinese man.", + "He complained of shortness of breath on exertion for 7 d.", + "He has a 13-year history of peripheral blood eosinophilia.", + "In August 2005, routine blood examination showed a white blood cell count of 8.5 × 109/L.", + "In August 2005, eosinophils accounted for 24.2% of white blood cells.", + "In August 2005, the eosinophil count was 2 × 109/L.", + "A bone marrow biopsy showed eosinophils accounted for 13.5%.", + "Most bone marrow eosinophils had normally segmented rod nuclei.", + "Oral triamcinolone was initiated at 4 mg, tid.", + "Eosinophil counts rapidly normalized after triamcinolone.", + "After 6 mo of gradual dosage reduction, hyperplastic and nodular changes developed in both breasts.", + "Abnormal lactation occurred after 6 mo of triamcinolone.", + "Bilateral axillary node enlargement occurred after 6 mo of triamcinolone.", + "Bilateral mastectomy was performed in January 2006 for chronic mastitis.", + "Postoperative pathology showed male breast development.", + "Postoperative pathology showed severe chronic inflammation.", + "Dilatation of mammary ducts was observed in postoperative pathology.", + "Interstitial influx of eosinophils was observed in postoperative pathology.", + "One month after mastectomy, the patient presented with joint pain of the trunk and limbs.", + "One month after mastectomy, movement dysfunction occurred.", + "One month after mastectomy, an exacerbated skin rash occurred.", + "Dexamethasone and prednisone were prescribed.", + "An herbal extract (Tripterygium wilfordii) was used shortly.", + "The herbal extract was abandoned due to severe treatment-related alopecia.", + "Joint symptoms gradually relented.", + "The patient resumed work after joint symptoms improved.", + "In April 2017, bilateral lower extremity edema developed spontaneously.", + "In April 2017, blood pressure was 150/100 mmHg.", + "In April 2017, plasma albumin was 15.6 g/L.", + "In April 2017, 24-h urinary protein was 14.78 g/d.", + "A clinical diagnosis of nephrotic syndrome was made.", + "A kidney biopsy was performed.", + "A pathologic diagnosis of focal segmental glomerulosclerosis, non-specific type, was made.", + "A second bone marrow puncture showed eosinophilia.", + "Qualitative polymerase chain reaction failed to detect the FIP1L1-PDGFRA fusion gene.", + "Prednisone was given orally at an initial dose of 60 mg per day.", + "Prednisone was gradually reduced and discontinued in March 2018.", + "All parameters of nephrotic syndrome were stable in March 2018.", + "One month after medication withdrawal, hospital readmission occurred in April 2018.", + "The readmission was due to shortness of breath.", + "He initially presented in December 2004 with constipation, abdominal distension, and persistent vomiting.", + "Gastroscopic inspection revealed superficial gastritis.", + "Gastroscopic inspection revealed duodenal bulbar inflammation.", + "Gastroscopic inspection revealed gastric retention.", + "Enteroscopy showed rectosigmoid mucositis.", + "Interstitial inflammatory infiltrates were prominent in gastric mucosal biopsies.", + "Interstitial inflammatory infiltrates were prominent in colonic mucosal biopsies.", + "Digestive symptoms gradually abated and disappeared after symptomatic treatment.", + "Several months later, the patient developed an erythematous papular skin rash.", + "The rash coalesced in places.", + "The rash was largely confined to the dorsa of hands and limbs.", + "The rash had a symmetric distribution.", + "The rash was without itching.", + "Vitiligo chiefly affected the face and trunk.", + "The patient was born prematurely at 8 mo of gestation.", + "The patient had one episode of pertussis during childhood.", + "The patient had many instances of pneumonia.", + "The patient’s father had succumbed to gastric cancer at age 50.", + "Physical examination revealed alopecia.", + "Physical examination revealed loss of facial and trunk pigmentation.", + "An erythematous rash was observed on the dorsa of both hands and limbs.", + "No dry or wet rales were detected in either lung.", + "Blood eosinophil count was 0.41 × 109/L.", + "Total IgE was 1491 IU/ml.", + "PaO2 was 53.6 mmHg.", + "SaO2 was 91.2%.", + "In bronchoscopic alveolar lavage fluid, eosinophils represented 30.0% of cells.", + "Chest CT showed interstitial pneumonia." + ], + "summary": "A 43 year-old Chinese man with a 13-year history of eosinophilia and shortness of breath for 7 d presented to our hospital. During the course of his illness, the patient variably presented with gastrointestinal symptoms, eczema, vitiligo, mastitis, joint symptoms, nephrotic syndrome, and interstitial pneumonia. The chronic mastitis proved burdensome, necessitating bilateral mastectomy. HE was diagnosed by repeat bone marrow biopsy, and a kidney biopsy showed focal segmental glomerulosclerosis. Intermittent steroidal therapy is typically initiated to relieve such symptoms, although relapse and organ involvement often ensue once treatment is withdrawn. We administered methylprednisolone sodium succinate (40 mg/d) intravenously for 3 d, followed by oral tablets at the same dose. Subsequent computed tomography (CT) of the chest CT showed relative improvement of the interstitial pneumonia. The patient is currently on a continuous regimen of oral steroid, and his condition is stable.", + "summary_subclaims": [ + "The patient is a 43 year-old Chinese man.", + "The patient has a 13-year history of eosinophilia.", + "The patient had shortness of breath for 7 d.", + "The patient variably presented with gastrointestinal symptoms.", + "The patient variably presented with eczema.", + "The patient variably presented with vitiligo.", + "The patient variably presented with mastitis.", + "The patient variably presented with joint symptoms.", + "The patient variably presented with nephrotic syndrome.", + "The patient variably presented with interstitial pneumonia.", + "The chronic mastitis necessitated bilateral mastectomy.", + "The diagnosis was made by repeat bone marrow biopsy.", + "A kidney biopsy showed focal segmental glomerulosclerosis.", + "Intermittent steroidal therapy is typically initiated to relieve symptoms.", + "Relapse and organ involvement often ensue once treatment is withdrawn.", + "Methylprednisolone sodium succinate (40 mg/d) was administered intravenously for 3 d.", + "Subsequent computed tomography (CT) of the chest showed relative improvement of the interstitial pneumonia.", + "The patient is currently on a continuous regimen of oral steroid.", + "The patient's condition is stable." + ] + }, + { + "id": "multiclinsum_test_1833_en.txt", + "fulltext": "A 47-year-old Asian woman was admitted to our hospital with a 1-year history of worsening leg numbness and urinary dysfunction. She first noticed her bilateral 3rd and 4th toe numbness for 5 years. Her symptoms worsened, and her whole toes became numb a year ago. She had also been experiencing frequent urination for a year. She visited her previous physician and was referred to our hospital after magnetic resonance imaging was taken. On physical examination, her motor function was intact, but she had sensory disturbance around the anal region. Deep tendon reflexes were normal. Her finger–floor distance was 10 cm, and her straight leg raise test result was 80 degrees; this indicated that her hamstrings were not tight. Magnetic resonance imaging revealed a low-lying conus medullaris extending to the level of S2 and surrounded by fat tissue at that level . The spinal MRI did not point to any other abnormalities that could explain her symptoms. We diagnosed her condition as adult tethered cord syndrome, and spine-shortening vertebral osteotomy was planned. After the patient provided informed consent, she underwent shortening osteotomy.\nAfter induction of general anesthesia, the patient was positioned onto a Jackson Spinal Table (Mizuho Co. Ltd., Tokyo, Japan). Neurophysiological monitoring was performed using motor evoked potentials. A midline incision was made from the T11 to L4 spinous process level. The target level for the osteotomy was L2. The L2 segment was extensively exposed, in turn exposing the posterior element and transverse processes bilaterally. Bilateral pedicle screw implants were placed at L1 and L3 using an anterior–posterior image intensifier. In this procedure, it is essential to use monoaxial screws inserted exactly parallel to the rostral endplates of each vertebral body; this ensures appropriate alignment between the L1 caudal endplate and the L2 osteotomy surface. The osteotomy was started after insertion of the pedicle screws. First, the lower half of the L1 lamina and bilateral inferior articular processes of L1 as well as the bilateral L2 superior articular processes were resected. Second, the upper one-third of the lamina of L2 was resected, and the bilateral two-thirds of the pedicle of L2 was removed with a surgical air drill. Resection of the upper one-third of the lamina of L2 is very important to prevent postoperative neurological deterioration due to epidural hematoma formation. Although bone union can effectively occur without resection of the lamina, the dural space will be so tight that only a small hematoma will be symptomatic. After exposure of the lateral side of the L1–2 disc, discectomy was performed with a knife and curette. Following complete discectomy of L1–2, the upper vertebral body of L2 was removed with a surgical air drill. The surgical air drill was inserted from the pedicle parallel to the upper endplate of L2, and the posterior wall of the vertebral body was thus removed. After thinning of the lateral vertebral cortex, the lateral surface of the vertebral body was carefully exposed, and the lateral cortex was removed with a punch. After thinning of the anterior vertebral cortex, a Kerrison rongeur was used to remove the anterior cortex. Because the anterior longitudinal ligament protects the vessels and anterior organs, little bleeding occurred when the anterior body was removed. After complete removal of the vertebral body, a straight rod was connected to two screws and applied pressure between the screws. Two polyethylene tapes (Alfresa Pharma Corporation, Osaka, Japan) were applied to the L2 lamina and bilateral rods. A drawing of the surgery is shown in Fig. . The operation time was 5 h 13 min, and the estimated blood loss was 108 ml. In this case, there was less degeneration, and the epidural venous plexus was less developed, which may have been the reason for the small amount of blood loss.\nThe tips and tricks of this procedure are as follows. (1) Carefully develop the sides of the vertebral body and intervertebral disc with hemostasis; (2) use the endplate of the vertebral body as a guide and insert an air tome parallel to the endplate to resect the vertebral body; (3) leave the lateral wall of the vertebral body like an eggshell and complete the resection by resecting the shell at the end.\nThe postoperative course was uneventful. The postoperative radiograph showed 18-mm shortening from the L1 upper endplate to the L2 lower endplate . The patient’s leg numbness improved immediately after surgery, and her urinary disturbance improved 1 year after surgery, although magnetic resonance imaging did not show evidence of untethering. Computed tomography 1 year after the operation showed complete bone union ; therefore, we removed the instrumentation. She had developed no recurrence at 2 years after surgery.", + "fulltext_subclaims": [ + "The patient was a 47-year-old Asian woman.", + "She had a 1-year history of worsening leg numbness and urinary dysfunction.", + "She first noticed bilateral 3rd and 4th toe numbness 5 years ago.", + "Her whole toes became numb a year ago.", + "She had been experiencing frequent urination for a year.", + "Magnetic resonance imaging was taken.", + "On physical examination, her motor function was intact.", + "She had sensory disturbance around the anal region.", + "Deep tendon reflexes were normal.", + "Her finger–floor distance was 10 cm.", + "Her straight leg raise test result was 80 degrees.", + "Magnetic resonance imaging revealed a low-lying conus medullaris extending to the level of S2.", + "The spinal MRI did not point to any other abnormalities that could explain her symptoms.", + "We diagnosed her condition as adult tethered cord syndrome.", + "Spine-shortening vertebral osteotomy was planned.", + "The patient provided informed consent.", + "She underwent shortening osteotomy.", + "The patient was positioned onto a Jackson Spinal Table.", + "Neurophysiological monitoring was performed using motor evoked potentials.", + "A midline incision was made from the T11 to L4 spinous process level.", + "The target level for the osteotomy was L2.", + "Bilateral pedicle screw implants were placed at L1 and L3.", + "The osteotomy was started after insertion of the pedicle screws.", + "The lower half of the L1 lamina and bilateral inferior articular processes of L1 as well as the bilateral L2 superior articular processes were resected.", + "The upper one-third of the lamina of L2 was resected.", + "The bilateral two-thirds of the pedicle of L2 was removed with a surgical air drill.", + "Resection of the upper one-third of the lamina of L2 is very important to prevent postoperative neurological deterioration due to epidural hematoma formation.", + "After complete discectomy of L1–2, the upper vertebral body of L2 was removed with a surgical air drill.", + "The surgical air drill was inserted from the pedicle parallel to the upper endplate of L2.", + "The posterior wall of the vertebral body was thus removed.", + "After thinning of the lateral vertebral cortex, the lateral surface of the vertebral body was carefully exposed.", + "The lateral cortex was removed with a punch.", + "After thinning of the anterior vertebral cortex, a Kerrison rongeur was used to remove the anterior cortex.", + "Little bleeding occurred when the anterior body was removed.", + "After complete removal of the vertebral body, a straight rod was connected to two screws and applied pressure between the screws.", + "Two polyethylene tapes were applied to the L2 lamina and bilateral rods.", + "The operation time was 5 h 13 min.", + "The estimated blood loss was 108 ml.", + "In this case, there was less degeneration.", + "The epidural venous plexus was less developed.", + "The tips and tricks of this procedure are as follows.", + "Carefully develop the sides of the vertebral body and intervertebral disc with hemostasis.", + "Use the endplate of the vertebral body as a guide and insert an air tome parallel to the endplate to resect the vertebral body.", + "Leave the lateral wall of the vertebral body like an eggshell and complete the resection by resecting the shell at the end.", + "The postoperative course was uneventful.", + "The postoperative radiograph showed 18-mm shortening from the L1 upper endplate to the L2 lower endplate.", + "The patient’s leg numbness improved immediately after surgery.", + "Her urinary disturbance improved 1 year after surgery.", + "Magnetic resonance imaging did not show evidence of untethering.", + "Computed tomography 1 year after the operation showed complete bone union.", + "We removed the instrumentation.", + "She had developed no recurrence at 2 years after surgery." + ], + "summary": "A 47-year-old Asian woman was admitted to our hospital with a 1-year history of worsening leg numbness and urinary dysfunction. Magnetic resonance imaging revealed a low-lying conus medullaris extending to the level of S2 and surrounded by fat tissue at that level. We diagnosed her condition as adult tethered cord syndrome, and spine-shortening vertebral osteotomy was planned. The target level for the osteotomy was L2. Bilateral pedicle screw implants were placed at L1 and L3 using an anterior-posterior image intensifier. In this procedure, it is essential to use monoaxial screws inserted exactly parallel to the rostral endplates of each vertebral body; this ensures appropriate alignment between the L1 caudal endplate and the L2 osteotomy surface. The upper one-third of the lamina of L2 was resected, and the bilateral two-thirds of the pedicle of L2 was removed with a surgical air drill. After exposure of the lateral side of the L1-2 disc, discectomy was performed with a knife and curette. Following complete discectomy of L1-2, the upper vertebral body of L2 was removed with a surgical air drill. After complete removal of the vertebral body, a straight rod was connected to two screws and applied pressure between the screws. Two polyethylene tapes were applied to the L2 lamina and bilateral rods.", + "summary_subclaims": [ + "The patient was a 47-year-old Asian woman.", + "She had a 1-year history of worsening leg numbness.", + "She had urinary dysfunction.", + "Magnetic resonance imaging revealed a low-lying conus medullaris extending to the level of S2.", + "The conus medullaris was surrounded by fat tissue at the level of S2.", + "The diagnosis was adult tethered cord syndrome.", + "Spine-shortening vertebral osteotomy was planned.", + "The target level for the osteotomy was L2.", + "Bilateral pedicle screw implants were placed at L1 and L3.", + "An anterior-posterior image intensifier was used.", + "It is essential to use monoaxial screws inserted exactly parallel to the rostral endplates of each vertebral body.", + "The upper one-third of the lamina of L2 was resected.", + "The bilateral two-thirds of the pedicle of L2 was removed with a surgical air drill.", + "After exposure of the lateral side of the L1-2 disc, discectomy was performed with a knife and curette.", + "Following complete discectomy of L1-2, the upper vertebral body of L2 was removed with a surgical air drill.", + "After complete removal of the vertebral body, a straight rod was connected to two screws.", + "Two polyethylene tapes were applied to the L2 lamina and bilateral rods." + ] + }, + { + "id": "multiclinsum_test_2854_en.txt", + "fulltext": "A 28-year-old female patient of Indian ethnicity was referred to our specialist gynaecology clinic after presenting to her general practitioner with a few weeks’ history of right-sided lower abdominal pain, radiating to the right flank. An ultrasound scan performed in primary care showed a right adnexal solid cystic mass, initiating urgent referral to the rapid access gynaecological cancer service.\nThe patient had no history of any medical conditions. She was nulliparous with a BMI of 27 and no previous gynaecological or surgical history. She described an unremarkable menstrual history with regular cycles, and no menorrhagia, dysmenorrhoea or intermenstrual bleeding. She was not using any regular medication or contraceptives, and had no family history of gynaecological conditions or cancer. Her 3-yearly cervical cytology testing was up to date and unremarkable. She was a non-smoker and consumed alcohol socially.\nAbdominal and bimanual vaginal examination was deemed inconclusive but revealed no obvious abnormalities. Vaginal speculum examination demonstrated no abnormalities of the vulva, vagina and cervix. A transvaginal ultrasound performed in the expert, specialist clinic showed an anteverted, normal sized uterus, with an endometrial thickness of 16mm. Anechoic areas with Doppler colour flow were seen in the endometrial cavity, suggestive of endometrial polyps. The rest of the endometrium was regular and well defined with preservation of the endo-myometrial junction. . The left ovary appeared normal. In the right adnexa, a solid cystic mass measuring 74 x 58 x 63 mm was seen, with the solid component measuring 40 mm with shadowing . The mass had a colour score of 3, suggestive of moderate blood flow through the mass .\nAccording to IOTA simple rules, the mass was indeterminate because of shadowing, a benign feature, and colour score of 3, which was a malignant feature .\nThe IOTA-ADNEX risk model was subsequently used to evaluate the ovarian lesion. This suggested a 44.2% risk of being benign and a 55.8% risk of ovarian malignancy, of which borderline was 36.7%, followed by a 12% risk of being stage 1 ovarian cancer. Risk of stage 2-4 ovarian cancer was 5.2%. Risk of metastatic ovarian cancer was 2% .\nOn subjective assessment, the mass was suspected to be a sex-cord stromal tumour.\nFollowing initial assessment, due to the indeterminate nature of the adnexal mass, a plan was made to obtain serum tumour markers, perform magnetic resonance imaging (MRI) and to discuss the case in the specialist gynaecological cancer multidisciplinary team (MDT) meeting.\nAll tumour markers tested were normal (CA125 29, AFP 1, HCG <2, and LDH 153).\nPelvic MRI showed a polypoid lesion in the uterine cavity. The left ovary appeared normal. The right adnexal mass was identified within a pool of free ascitic fluid, which extended both behind and in front of the uterus. The mass had bright uptake on T1 weighted series and featured small cysts, suggestive of an enlarged, torted, solid cystic right ovarian mass . The MRI was inconclusive of malignancy because of the distorted architecture caused by the torsion. A staging computer tomography (CT) of the chest, abdomen and pelvis did not show any evidence of local or distant metastasis.\nHysteroscopy unveiled multiple polyps in the lower uterine cavity; the endometrium appeared normal at the uterine fundus. Transcervical resection of the uterine polyps was performed. Laparoscopy confirmed an 8cm right-sided, cystic and solid, torted mass with omental and peritoneal adhesions and minimal inflammatory ascites. Following removal of the ascitic fluid, careful examination did not reveal any other abnormalities inside the abdominal cavity. Adhesiolysis followed by uncomplicated right salpingo-oophorectomy was performed and the specimen was removed inside an Endobag without spillage. All the specimens were sent for histological analysis.\nThe endometrial polypoid tissue showed changes consistent with grade 1 endometrioid endometrial adenocarcinoma . Sections from the right ovarian mass showed features in keeping with a well-differentiated endometrioid ovarian carcinoma . Possible endometriosis was also identified. It was uncertain as to whether the endometrial and ovarian lesions were synchronous tumours or represented metastatic deposits. Immunohistochemistry for mismatch repair proteins (MMR) was undertaken on the right ovarian mass and the tumour cells showed normal nuclear staining for MLH1, PMS2, MSH2 and MSH6.\nThe patient was re-discussed at the specialist oncology MDT meeting. Based on the histological findings, the MDT consensus was of a diagnosis of International Federation of Gynaecology and Obstetrics stage 1A, grade 1 endometrioid endometrial adenocarcinoma, and FIGO stage 1A well differentiated endometrioid carcinoma of the right ovary, incompletely staged.", + "fulltext_subclaims": [ + "The patient is a 28-year-old female of Indian ethnicity.", + "She was referred to a specialist gynaecology clinic after presenting with right-sided lower abdominal pain.", + "An ultrasound scan in primary care showed a right adnexal solid cystic mass.", + "The patient had no history of medical conditions.", + "She was nulliparous with a BMI of 27.", + "She had no previous gynaecological or surgical history.", + "Her menstrual history was regular with no menorrhagia, dysmenorrhoea, or intermenstrual bleeding.", + "She was not using any regular medication or contraceptives.", + "Her 3-yearly cervical cytology testing was up to date and unremarkable.", + "Abdominal and bimanual vaginal examination was inconclusive.", + "A transvaginal ultrasound showed an anteverted, normal sized uterus.", + "The endometrial thickness was 16mm.", + "Anechoic areas with Doppler colour flow were seen in the endometrial cavity, suggestive of endometrial polyps.", + "The rest of the endometrium was regular and well defined with preservation of the endo-myometrial junction.", + "The left ovary appeared normal.", + "A solid cystic mass measuring 74 x 58 x 63 mm was seen in the right adnexa.", + "The solid component of the mass measured 40 mm with shadowing.", + "The mass had a colour score of 3, suggestive of moderate blood flow.", + "According to IOTA simple rules, the mass was indeterminate.", + "The IOTA-ADNEX risk model suggested a 44.2% risk of being benign.", + "The IOTA-ADNEX risk model suggested a 55.8% risk of ovarian malignancy.", + "The risk of stage 1 ovarian cancer was 12%.", + "The risk of stage 2-4 ovarian cancer was 5.2%.", + "The risk of metastatic ovarian cancer was 2%.", + "On subjective assessment, the mass was suspected to be a sex-cord stromal tumour.", + "A plan was made to obtain serum tumour markers.", + "A plan was made to perform magnetic resonance imaging (MRI).", + "A plan was made to discuss the case in the specialist gynaecological cancer multidisciplinary team (MDT) meeting.", + "All tumour markers tested were normal.", + "Pelvic MRI showed a polypoid lesion in the uterine cavity.", + "The right adnexal mass was identified within a pool of free ascitic fluid.", + "The mass had bright uptake on T1 weighted series and featured small cysts.", + "The MRI was inconclusive of malignancy.", + "Hysteroscopy unveiled multiple polyps in the lower uterine cavity.", + "Transcervical resection of the uterine polyps was performed.", + "Laparoscopy confirmed an 8cm right-sided, cystic and solid, torted mass.", + "Adhesiolysis followed by right salpingo-oophorectomy was performed.", + "The specimen was removed inside an Endobag without spillage.", + "The endometrial polypoid tissue showed changes consistent with grade 1 endometrioid endometrial adenocarcinoma.", + "Sections from the right ovarian mass showed features in keeping with a well-differentiated endometrioid ovarian carcinoma.", + "It was uncertain whether the endometrial and ovarian lesions were synchronous tumours or represented metastatic deposits.", + "Immunohistochemistry for mismatch repair proteins was undertaken on the right ovarian mass.", + "The tumour cells showed normal nuclear staining for MLH1, PMS2, MSH2 and MSH6.", + "The MDT consensus was of a diagnosis of FIGO stage 1A well differentiated endometrioid carcinoma of the right ovary." + ], + "summary": "A 28-year-old woman was referred to our department with lower abdominal pain. Transvaginal ultrasound showed a complex right adnexal mass with mixed echogenicity. Magnetic resonance imaging (MRI) identified a right-sided, torted, cystic solid ovarian mass, and a polypoid lesion in the uterine cavity.", + "summary_subclaims": [ + "The patient is a 28-year-old woman.", + "The patient was referred to our department with lower abdominal pain.", + "Transvaginal ultrasound showed a complex right adnexal mass with mixed echogenicity.", + "MRI identified a right-sided, torted, cystic solid ovarian mass.", + "MRI identified a polypoid lesion in the uterine cavity." + ] + }, + { + "id": "multiclinsum_test_282_en.txt", + "fulltext": "A 37-year-old female patient was admitted to local hospital on January 28, 2023, due to chest tightness and dyspnea for 4 h. The patient reported no previous history of HIV/AIDS, organ transplantation, corticosteroid use, or immunosuppressive medications. Before admission, the woman had a car accident and drowned in a private fishpond. After being rescued, she developed chest tightness and breathing difficulties which were assumed to be due to water aspiration. The lung computed tomography (CT) scan showed bilateral pulmonary edema with multiple high-density nodular shadows. The head CT showed no apparent abnormalities . She was then started on corticosteroids, diuretics, and antibiotics for 12 days which was discontinued when her respiratory symptoms were improved. However, she developed a new headache and subsequently, rapid cognitive decline, aphasia, lethargy, and impaired consciousness. Physical examination revealed significant muscle weakness in the left limb (grade 2), compared to her right limb (grade 4). The second head CT showed multiple annular high-density shadows with slightly low-density shadows around it. A head magnetic resonance imaging (MRI) showed multiple ring reinforcement nodules with cerebral edema, which raised the concern for multiple intracranial metastatic lesions. Thus, a positron emission tomography–computed tomography (PET/CT) was performed and revealed multiple hypermetabolic nodules within the cranium and lungs, suggesting a high probability of infection. The metagenomic next-generation sequencing (mNGS) and culture of cerebrospinal fluid (CSF) detected no specific pathogen.\nAfter a course of antibiotics treatment, her headache aggravated, fever and vomiting occurred, and muscle strength further decreased (left limb: grade 1, right limb: grade 3). Additionally, decreased vision of the left eye and mild conjunctival congestion appeared. She was then transferred to the Department of Neurosurgery of our hospital.\nThe puncture drainage of intracranial lesions was performed and the pus was tested by mNGS. A total of 600ul brain abscess drainage fluid samples were collected and mixed by glass beads. DNA was extracted by column extraction method. The libraries were constructed using end repair, and specific tag sequences were introduced at the end of each library. The size of library inserts to be sequenced was determined using an Agilent 2100 Bioanalyzer (G2939BA, Agilent, USA). DNA nanospheres were prepared using a one-step DNB preparation kit (1,000,025,076, Huada Gene Technology Co. Ltd, Shenzhen, China). Sequencing was performed on the MGISEQ-200 sequencing platform. Then the reads containing sequencing adapter, low quality, short (length < 35 bp) and low complexity were removed, and aligned to the human reference genome (hg38) using STAR software (v2.7.1a) to remove the host reads. The remaining non-host reads were searched and classified against four self-built pathogenic microorganism genome databases, including bacteria, fungi, parasites and viruses. Finally, S. apiospermum was detected with a coverage of 99.45%. At our hospital, the patient was conscious, but with difficulty speaking, grade 2 muscle strength of the left limb, grade 4 for the right limb, and positive Babinski’s sign on the left side. The neck rigidity was present and the Kernig sign was positive. Antifungal therapy started (voriconazole 200 mg bid, ivgtt). Dehydration (mannitol) to reduce intracranial pressure and low-dose glucocorticoids (methylprednisolone 40 mg qd, ivgtt) were also used. Two days later, the patient developed severe conjunctival congestion of the left eye with no light perception, and in less than one day, the left eye rapidly progressed to yellow-green vitreous opacity, with an unclear pupil .\nOphthalmic physical examination revealed no light perception in the left eye, hyperemia and Tyndall’s. The cornea was clear, however, a thick exudative membrane in the pupil was present, and the fundus was unclear. Eye ultrasound showed vitreous opacity in the left eye. The patient was treated with fluconazole and voriconazole eye drops combined with antibiotics. The infection was resolved, but her visual acuity was not improved. One week after the antifungal treatment, a head MRI showed that the brain lesions became smaller in size, however severe edema around the lesions was still present. The lung CT showed the lung lesions were significantly improved compared to the previous CT. The headache and dizziness were alleviated, and there was no significant change in muscle strength. Two weeks later, an orbital MRI showed an abnormal signal of the left eyeball with enhancement. The patient’s muscle strength was significantly improved as the muscle strength of the left limb was grade 4-, and the right limb was grade 5. Two weeks later, the head MRI and lung CT showed that the abscess lesions became smaller. The pupil of the left eye was clear, but the eyeball atrophy and vision did not improve . After discharge, the patient was prescribed to continue voriconazole (200 mg bid po) and rehabilitation therapy.\nThe patient has been followed up for over 7 months, and the brain and lung lesions were smaller than before, but have not completely disappeared . Figure summarizes the timeline of the case.", + "fulltext_subclaims": [ + "The patient was admitted to local hospital on January 28, 2023.", + "The patient reported no previous history of HIV/AIDS.", + "The patient reported no previous history of organ transplantation.", + "The patient reported no previous history of corticosteroid use.", + "The patient reported no previous history of immunosuppressive medications.", + "The patient had a car accident and drowned in a private fishpond.", + "After being rescued, she developed chest tightness and breathing difficulties.", + "The chest tightness and breathing difficulties were assumed to be due to water aspiration.", + "The lung CT scan showed bilateral pulmonary edema with multiple high-density nodular shadows.", + "The head CT showed no apparent abnormalities.", + "She was started on corticosteroids, diuretics, and antibiotics.", + "The corticosteroids, diuretics, and antibiotics were discontinued after 12 days.", + "The corticosteroids, diuretics, and antibiotics were discontinued when her respiratory symptoms were improved.", + "She developed a new headache.", + "She developed rapid cognitive decline.", + "She developed aphasia.", + "She developed lethargy.", + "She developed impaired consciousness.", + "Physical examination revealed significant muscle weakness in the left limb (grade 2).", + "Physical examination revealed muscle strength of grade 4 in the right limb.", + "The second head CT showed multiple annular high-density shadows with slightly low-density shadows around it.", + "A head MRI showed multiple ring reinforcement nodules with cerebral edema.", + "The head MRI raised the concern for multiple intracranial metastatic lesions.", + "A PET/CT was performed.", + "The PET/CT revealed multiple hypermetabolic nodules within the cranium and lungs.", + "The PET/CT suggested a high probability of infection.", + "The mNGS and culture of CSF detected no specific pathogen.", + "After a course of antibiotics treatment, her headache aggravated.", + "After a course of antibiotics treatment, fever and vomiting occurred.", + "After a course of antibiotics treatment, muscle strength further decreased (left limb: grade 1, right limb: grade 3).", + "Decreased vision of the left eye appeared.", + "Mild conjunctival congestion appeared.", + "She was transferred to the Department of Neurosurgery of our hospital.", + "The puncture drainage of intracranial lesions was performed.", + "The pus was tested by mNGS.", + "A total of 600ul brain abscess drainage fluid samples were collected and mixed by glass beads.", + "DNA was extracted by column extraction method.", + "The libraries were constructed using end repair.", + "Specific tag sequences were introduced at the end of each library.", + "The size of library inserts to be sequenced was determined using an Agilent 2100 Bioanalyzer.", + "DNA nanospheres were prepared using a one-step DNB preparation kit.", + "Sequencing was performed on the MGISEQ-200 sequencing platform.", + "Reads containing sequencing adapter, low quality, short (length < 35 bp), and low complexity were removed.", + "The reads were aligned to the human reference genome (hg38) using STAR software.", + "The remaining non-host reads were searched and classified against four self-built pathogenic microorganism genome databases.", + "S. apiospermum was detected with a coverage of 99.45%.", + "At our hospital, the patient was conscious.", + "The patient had difficulty speaking.", + "The patient had grade 2 muscle strength of the left limb.", + "The patient had grade 4 muscle strength of the right limb.", + "The patient had positive Babinski’s sign on the left side.", + "The patient had neck rigidity.", + "The patient had a positive Kernig sign.", + "Antifungal therapy started (voriconazole 200 mg bid, ivgtt).", + "Dehydration (mannitol) to reduce intracranial pressure was used.", + "Low-dose glucocorticoids (methylprednisolone 40 mg qd, ivgtt) were used.", + "Two days later, the patient developed severe conjunctival congestion of the left eye with no light perception.", + "In less than one day, the left eye rapidly progressed to yellow-green vitreous opacity.", + "The pupil was unclear.", + "Ophthalmic physical examination revealed no light perception in the left eye.", + "Ophthalmic physical examination revealed hyperemia and Tyndall’s.", + "The cornea was clear.", + "A thick exudative membrane in the pupil was present.", + "The fundus was unclear.", + "Eye ultrasound showed vitreous opacity in the left eye.", + "The patient was treated with fluconazole and voriconazole eye drops combined with antibiotics.", + "The infection was resolved.", + "Her visual acuity was not improved.", + "One week after the antifungal treatment, a head MRI showed that the brain lesions became smaller in size.", + "Severe edema around the lesions was still present.", + "The lung CT showed the lung lesions were significantly improved compared to the previous CT.", + "The headache and dizziness were alleviated.", + "There was no significant change in muscle strength.", + "Two weeks later, an orbital MRI showed an abnormal signal of the left eyeball with enhancement.", + "The patient’s muscle strength was significantly improved as the muscle strength of the left limb was grade 4-.", + "The patient’s muscle strength was significantly improved as the muscle strength of the right limb was grade 5.", + "Two weeks later, the head MRI and lung CT showed that the abscess lesions became smaller.", + "The pupil of the left eye was clear.", + "The eyeball atrophy and vision did not improve.", + "After discharge, the patient was prescribed to continue voriconazole (200 mg bid po).", + "After discharge, the patient was prescribed to continue rehabilitation therapy.", + "The patient has been followed up for over 7 months.", + "The brain and lung lesions were smaller than before.", + "The brain and lung lesions have not completely disappeared." + ], + "summary": "A 37-year-old woman presented with multiple lesions in the lungs, brain, and eyes, shortly after near drowning in a car accident. The primary symptoms were chest tightness, limb weakness, headache, and poor vision in the left eye. S. apiospermum infection was confirmed by metagenomic next-generation sequencing (mNGS) of intracranial abscess drainage fluid, although intracranial metastases were initially considered. After systemic treatment with voriconazole, her symptoms improved significantly; however, she lost vision in her left eye due to delayed diagnosis.", + "summary_subclaims": [ + "The patient is a 37-year-old woman.", + "She presented with multiple lesions in the lungs, brain, and eyes.", + "The presentation occurred shortly after a near drowning in a car accident.", + "The primary symptoms were chest tightness, limb weakness, headache, and poor vision in the left eye.", + "S. apiospermum infection was confirmed by metagenomic next-generation sequencing of intracranial abscess drainage fluid.", + "Intracranial metastases were initially considered.", + "After systemic treatment with voriconazole, her symptoms improved significantly.", + "She lost vision in her left eye due to delayed diagnosis." + ] + }, + { + "id": "multiclinsum_test_558_en.txt", + "fulltext": "A 37-year-old Hispanic woman without a significant past medical history presented to our hospital with a one week history of shortness of breath, which had acutely worsened over the past few days. She stated that she required two pillows to breathe while lying down. She also stated that she could no longer work at her childrens' day care center, as even walking at a relaxed pace for more than two minutes would cause her to be short of breath, although the shortness of breath would improve with rest. She also complained of a nonproductive cough for two days before admission. She denied any trauma, chest pain, palpitations, nausea and vomiting, diarrhea, abdominal pain, or fevers. Review of systems was remarkable for a one month history of bilateral lower extremity edema.\nShe denied any significant past medical history and had not been taking any medication before hospital admission. She remotely recalled that her last physician, whom she had not seen in the previous eight years, had mentioned to her that she might have hypothyroidism, but this was not further investigated. She denied use of tobacco, alcohol, or any other recreational drugs.\nPhysical examination revealed an obese, pale woman in mild distress from shortness of breath, but able to speak in full sentences. Her vital signs on arrival showed an oral temperature of 36.8°C, heart rate in the range of 81 to 93 beats per minute, blood pressures ranging from 140 to 173 mm Hg systolic and 94 to 121 mm Hg diastolic. Her breathing was 18 to 22 times per minute, with a digital pulse oximetry saturation of 86% while breathing air, which subsequently improved to 92% when she was given oxygen therapy via a face mask. Her neck examination showed no nodular thyroid or thyroid masses. There was no lymphadenopathy. Dullness to percussion was found over the lower portion of her left hemithorax, accompanied by decreased vocal fremitus, as well as decreased breath sounds on auscultation. The chest examination was normal over her right hemithorax. Cardiac examination revealed no murmurs, rubs, or gallops, but heart sounds were generally distant. Abdominal examination was unremarkable, with no signs of ascites or masses. Lower extremities revealed 2+ pitting edema to the level of the knees bilaterally.\nHer electrocardiogram showed low voltage throughout all leads with no other ST-segment or T-wave abnormalities. A chest radiograph showed an enlarged cardiac silhouette and bilateral pleural effusions, with more fluid on the left than on the right. A computed tomography (CT) angiogram of the chest did not reveal pulmonary thromboembolism and confirmed the presence of a large left pleural effusion with associated compressive atelectasis, as well as a moderate pericardial effusion .\nAdmission laboratory values demonstrated a leukocyte count of 6.3 × 109/L (normal, 3.5 to 11.0 × 109/L) with a hematocrit of 36% (normal, 36% to 46%). A chemistry panel was remarkable for a creatinine of 1.4 mg/dL (124 μmol/L; normal, 44 to 106 μmol/L). Troponin T cardiac enzyme was slightly elevated at 0.02 μg/L (normal, <0.01 μg/L), and beta-natriuretic peptide was elevated at 1325 ng/L (normal, 0 to 450 ng/L). Urine alaysis was significant for 2+ protein. A fasting lipid panel showed a total cholesterol of 179 mg/dL (4.64 mmol/L; normal, 3.65 to 5.15 mmol/L); triglycerides, 186 mg/dL (2.10 mmol/L; normal, <1.70 mmol/L), HDL, 25 mg/dL (0.65 mmol/L; normal: >1.01 mmol/L), and an LDL of 117 mg/dL (3.03 mmol/L; normal, 1.55 to 3.34 mmol/L). The liver panel showed a total protein of 7.0 g/dL (70 g/L; normal, 60 to 80 g/L) and albumin at 3.3 g/dL (33 g/L; normal, 35 to 50 g/L) with normal transaminases. Lactate dehydrogenase (LDH) was 302 U/L (normal, 112 to 220 U/L). Given her complaints of fatigue, a check of thyroid-stimulating hormone (TSH) and a free T4 levels were also carried out. The results of those tests showed the her TSH to be 181.90 mIU/L (normal, 0.27 to 4.2 mIU/L) and her free T4 to be <0.1 ng/dL (<1.29 pmol/L; normal, 0.9 to 1.7 pmol/L).\nThoracentesis on hospital day two revealed cloudy yellow fluid with 129 × 109/L white blood cells (23% neutrophils, 23% lymphocytes, 54% monocytes); a lactate dehydrogenase (LDH) level of 170 U/L, with a pleural fluid LDH-to-serum ratio of 0.56; a protein level of 5.6 g/dL (56 g/L), with a pleural fluid protein-to-serum ratio of 0.8; albumin of 2.8 g/dL (28 g/L); cholesterol of 81 mg/dL (2.10 mmol/L), with a pleural fluid cholesterol-to-serum ratio of 0.5; and triglycerides of 442 mg/dL (4.99 mmol/L), with a pleural fluid triglycerides-to-serum ratio of 2.4. These findings were thought to be compatible with an exudative chylous effusion. A 10-French chest tube was placed by our interventional radiologists the fourth day of her hospitalization. A follow-up chest CT after drainage of the effusion performed the seventh day of hospitalization showed a nonspecific retrocrural density that our radiologists thought to be compatible with swelling or inflammation related to her myxedema.\nTo investigate the etiology of her chylous effusion, she underwent nuclear medicine lymphatic scintigraphy on the following day to look for possible thoracic duct injury. The study showed normal tracer uptake throughout the lymphatic system without any evidence of accumulation to suggest leakage or trauma.\nShe was prescribed levothyroxine, 100 μg, slowly escalating to 150 μg orally per day for treatment of her hypothyroidism, along with a low-fat diet, and over the course of two weeks, her chest-tube drainage progressively decreased , and her fatigue and dyspnea subjectively improved. Her antithyroid peroxidase antibody was found to be elevated at 97.1 kIU/L (normal, <40 kIU/L), compatible with autoimmune thyroiditis. The chest tube was removed after ten days, and she was discharged home.\nAt two and three month follow-up visits, her fatigue had significantly improved, and she had returned to regular employment. Her TSH achieved a normal level (1.35 mIU/L; normal, 0.27 to 4.2 mIU/L). Follow-up chest radiographs and CT studies at two, three and six months showed near-complete resolution of the left chylous effusion, with complete resolution of the mild pericardial effusion. The retrocrural density seen on earlier CT studies has remained unchanged. At one year follow-up, no recurrence of her pleural effusion or clinical signs of malignancy have occurred.", + "fulltext_subclaims": [ + "The patient is a 37-year-old Hispanic woman.", + "She had a one week history of shortness of breath.", + "The shortness of breath had acutely worsened over the past few days.", + "She required two pillows to breathe while lying down.", + "She could no longer work at her children's day care center.", + "Walking at a relaxed pace for more than two minutes caused shortness of breath.", + "The shortness of breath improved with rest.", + "She had a nonproductive cough for two days before admission.", + "She denied any trauma.", + "She denied chest pain.", + "She denied palpitations.", + "She denied nausea and vomiting.", + "She denied diarrhea.", + "She denied abdominal pain.", + "She denied fevers.", + "She had a one month history of bilateral lower extremity edema.", + "She had not been taking any medication before hospital admission.", + "She remotely recalled that her last physician had mentioned she might have hypothyroidism.", + "She had not seen a physician in the previous eight years.", + "She denied use of tobacco.", + "She denied use of alcohol.", + "She denied use of recreational drugs.", + "Physical examination revealed an obese, pale woman in mild distress from shortness of breath.", + "Her vital signs on arrival showed an oral temperature of 36.8°C.", + "Her heart rate ranged from 81 to 93 beats per minute.", + "Her systolic blood pressure ranged from 140 to 173 mm Hg.", + "Her diastolic blood pressure ranged from 94 to 121 mm Hg.", + "Her breathing was 18 to 22 times per minute.", + "Her digital pulse oximetry saturation was 86% while breathing air.", + "Her saturation improved to 92% with oxygen therapy via a face mask.", + "Dullness to percussion was found over the lower portion of her left hemithorax.", + "There was decreased vocal fremitus on the left hemithorax.", + "There were decreased breath sounds on the left hemithorax.", + "The chest examination was normal over her right hemithorax.", + "Cardiac examination revealed no murmurs, rubs, or gallops.", + "Her electrocardiogram showed low voltage throughout all leads.", + "A chest radiograph showed an enlarged cardiac silhouette.", + "A chest radiograph showed bilateral pleural effusions.", + "A CT angiogram of the chest did not reveal pulmonary thromboembolism.", + "A CT angiogram confirmed the presence of a large left pleural effusion.", + "A CT angiogram showed compressive atelectasis on the left.", + "A CT angiogram showed a moderate pericardial effusion.", + "Admission laboratory values showed a leukocyte count of 6.3 × 109/L.", + "Admission laboratory values showed a hematocrit of 36%.", + "Admission laboratory values showed a creatinine of 1.4 mg/dL.", + "Admission laboratory values showed a troponin T of 0.02 μg/L.", + "Admission laboratory values showed a beta-natriuretic peptide of 1325 ng/L.", + "Urine analysis was significant for 2+ protein.", + "A fasting lipid panel showed a total cholesterol of 179 mg/dL.", + "A fasting lipid panel showed triglycerides of 186 mg/dL.", + "A fasting lipid panel showed HDL of 25 mg/dL.", + "A fasting lipid panel showed LDL of 117 mg/dL.", + "The liver panel showed a total protein of 7.0 g/dL.", + "The liver panel showed albumin at 3.3 g/dL.", + "Lactate dehydrogenase was 302 U/L.", + "A check of thyroid-stimulating hormone and free T4 levels was carried out.", + "Her TSH was 181.90 mIU/L.", + "Her free T4 was <0.1 ng/dL.", + "Thoracentesis revealed cloudy yellow fluid.", + "Thoracentesis showed 129 × 109/L white blood cells.", + "Thoracentesis showed a pleural fluid LDH-to-serum ratio of 0.56.", + "Thoracentesis showed a pleural fluid protein-to-serum ratio of 0.8.", + "Thoracentesis showed a pleural fluid cholesterol-to-serum ratio of 0.5.", + "Thoracentesis showed a pleural fluid triglycerides-to-serum ratio of 2.4.", + "The findings were thought to be compatible with an exudative chylous effusion.", + "A 10-French chest tube was placed by interventional radiologists on the fourth day of hospitalization.", + "A follow-up chest CT after drainage showed a nonspecific retrocrural density.", + "The retrocrural density was thought to be compatible with swelling or inflammation related to myxedema.", + "She underwent nuclear medicine lymphatic scintigraphy.", + "The study showed normal tracer uptake throughout the lymphatic system.", + "The study showed no evidence of accumulation to suggest leakage or trauma.", + "She was prescribed levothyroxine, 100 μg, escalating to 150 μg orally per day.", + "She was advised to follow a low-fat diet.", + "Her chest-tube drainage progressively decreased over two weeks.", + "Her fatigue and dyspnea subjectively improved.", + "Her antithyroid peroxidase antibody was elevated at 97.1 kIU/L.", + "The chest tube was removed after ten days.", + "She was discharged home.", + "At two and three month follow-up visits, her fatigue had significantly improved.", + "She had returned to regular employment.", + "Her TSH achieved a normal level of 1.35 mIU/L.", + "Follow-up chest radiographs and CT studies showed near-complete resolution of the left chylous effusion.", + "Follow-up studies showed complete resolution of the mild pericardial effusion.", + "The retrocrural density seen on earlier CT studies has remained unchanged.", + "At one year follow-up, no recurrence of her pleural effusion has occurred.", + "At one year follow-up, no clinical signs of malignancy have occurred." + ], + "summary": "A 37-year-old Hispanic woman with no reported significant past medical history initially presented with shortness of breath and inability to lose weight. She was found to have a large chylous effusion requiring chest-tube drainage, as well as severe hypothyroidism. After several weeks of thyroid hormone-replacement therapy, the formation of chylous pleural fluid in the patient greatly diminished, and the chest tube was removed. Upon long-term follow-up her minimal residual effusion remains stable on serial chest radiographs.", + "summary_subclaims": [ + "The patient is a 37-year-old Hispanic woman.", + "The patient had no reported significant past medical history.", + "The patient initially presented with shortness of breath.", + "The patient had an inability to lose weight.", + "The patient had a large chylous effusion requiring chest-tube drainage.", + "The patient had severe hypothyroidism.", + "After several weeks of thyroid hormone-replacement therapy, the formation of chylous pleural fluid in the patient greatly diminished.", + "The chest tube was removed.", + "Upon long-term follow-up, the patient's minimal residual effusion remains stable on serial chest radiographs." + ] + }, + { + "id": "multiclinsum_test_1789_en.txt", + "fulltext": "A 23-year-old man of Chinese descent presented to the emergency department for dyspnoea and pain in the left upper back. He had initially presented to the emergency department after an episode of severe vomiting following alcohol consumption and mild back pain three days prior, and was treated symptomatically and discharged. The patient denied any recent trauma. He had no other past medical issues nor known congenital conditions.\nUpon review, the patient was in severe respiratory distress and haemodynamically unstable with blood pressure of 95/70 mmHg, heart rate 162 beats per minute, respiratory rate of 40 breaths per minute and peripheral capillary oxygen saturation (SpO2) of 87% on 100% oxygen administered via non-rebreather mask. Although unable to lie still, he was oriented and able to speak in short phrases. His trachea was deviated and lung sounds were absent over his left chest.\nA chest X-ray (CXR) performed was interpreted as a moderately large left-sided pneumothorax with herniation of bowel into the left hemithorax . Due to patient instability, no computer tomography (CT) scan was performed after the CXR. A 14-gauge intravenous cannula was inserted into the second intercostal space along the mid-clavicular line for needle decompression in the sitting position.. However, air, followed by approximately 900 ml of faecal fluid, was aspirated, with no improvement in the patient’s symptoms. A repeat CXR showed a slight improvement of tracheal deviation, but with further bowel herniation taking up most of the left lung field. There was still concern that the pneumothorax had not been completely relieved.\nArterial blood gas (ABG) indicated severe combined respiratory and metabolic acidosis (pH 7.212, PaCO2 34.6 mmHg, PaO2 282 mmHg, base excess -14 and serum bicarbonate 13.9 mmol L-1. Serum lactate levels were elevated at 3.2 mg dL-1).\nThe patient was immediately transferred to the operating theatre for surgical intervention of his left diaphragmatic rupture, complicated by visceral herniation and possible left tension pneumothorax, with iatrogenic puncture of the herniated bowel. After discussion with the surgeons, a repeated needle decompression or chest tube insertion prior to induction of anaesthesia was not attempted due to the high failure rate attributed to the herniated bowel’s position, uncertain anatomy and the patient’s inability to cooperate.\nAfter adequate preoxygenation, rapid sequence induction was performed with cricoid pressure and intravenous propofol 150 mg, rocuronium 50 mg, and remifentanil target-controlled infusion at 1 ng ml-1. The SpO2 before induction was 92%, and the lowest SpO2 obtained while the airway was being secured was 80%. A left-sided double-lumen tube (DLT) was inserted and both the tracheal and bronchial cuffs were inflated immediately prior to the commencement of one lung ventilation. Rapid deflation of the left lung using a suction catheter was then carried out. Position of the left bronchial cuff was finally confirmed to be in the left main bronchus with a fiberoptic scope. Although the SpO2 improved to 100%, there was significant hypotension post-induction to lowest 63/45 mmHg, which was quickly addressed with boluses of phenylephrine and adrenaline to a total of 1000 μg and 30 μg respectively. An ABG obtained after induction showed pH 7.091, PaCO2 61.5 mmHg, PaO2 194 mmHg, base excess -11 and serum bicarbonate 18.7 mmol L-1.\nIntraoperatively, a 10 cm by 6 cm Bochdalek diaphragmatic hernia defect with herniation of the greater curve of stomach, spleen and long loop of transverse colon into the left hemithorax was found. A large perforation with necrotic edges in the greater curve of the stomach was also noted, with feculent material in the pleural and peritoneal cavity. No other obvious defects of the small and large bowels were seen.\nSimultaneous assessment and resuscitation of his persistent hypotension, tachycardia and hypoxia was carried out while surgery was ongoing. Based on the patient’s clinical history and operative findings, it was likely that he had a combination of obstructive, hypovolemic and distributive shocks due to tension pneumothorax, intravascular depletion and feculent peritonitis. He was aggressively fluid resuscitated with 1.8 litres of intravenous crystalloids and 2 litres of colloids. Noradrenaline and adrenaline infusions were commenced shortly after induction and maintained on 0.2 μg kg-1 min-1 for both infusions. His antibiotics were escalated from intravenous (IV) ceftriaxone and metronidazole to IV piperacillin-tazocin, and additional fungal coverage with IV anidulafungin was given. IV hydrocortisone was also administered. At the end of the surgery, he remained on noradrenaline 0.2 μg kg-1 min-1 and vasopressin 0.03 units kg-1 hr-1.\nAs the tension pneumothorax could not be surgically relieved until the herniated abdominal structures had been reduced, attempts were made to decompress the left pleural cavity with continued suction via the bronchial lumen of the left-sided DLT, to limited success. Eventually, a wedge gastrectomy of the stomach, diaphragmatic hernia reduction and left chest tube insertion was performed, followed by a temporary abdominal closure with the diaphragmatic defect being reinforced with surgical towels. Estimated blood loss was 800 ml and surgery lasted approximately 3 hours.\nA repeat ABG at the conclusion of the surgery showed persistent combined respiratory and metabolic acidosis (pH 7.153, PaCO2 54.5 mmHg, PaO2 128 mmHg, base excess -10 and serum bicarbonate 19.1 mmol L-1). The double-lumen tube was exchanged for a single-lumen tracheal tube and the patient was sent to the Intensive Care Unit (ICU) for continued resuscitation. Postoperatively, a repeated CXR showed reduction of the left diaphragmatic hernia with re-expansion of the left lung . Dual vasopressor support was weaned off on Day 2 of admission and the patient did not have high ventilatory requirements.\nThe patient returned to the operating theatre for a relook surgery on Day 3 of admission. The hernia defect was repaired with a synthetic mesh and primary abdominal closure was performed uneventfully. The patient was extubated on Day 5 of admission and discharged from the ICU on Day 6 of admission. CXR on Day 6 of admission showed resolution of pneumothorax and reduction of diaphragmatic hernia . After an additional 2 weeks’ stay for total parenteral nutrition and post-operative recovery, he was discharged home 22 days after admission.", + "fulltext_subclaims": [ + "The patient was a 23-year-old man of Chinese descent.", + "He presented to the emergency department for dyspnoea and pain in the left upper back.", + "He had initially presented to the emergency department three days prior.", + "He was treated symptomatically and discharged after the initial presentation.", + "He denied any recent trauma.", + "He had no other past medical issues nor known congenital conditions.", + "The patient was in severe respiratory distress.", + "He was haemodynamically unstable with blood pressure of 95/70 mmHg.", + "His heart rate was 162 beats per minute.", + "His respiratory rate was 40 breaths per minute.", + "His peripheral capillary oxygen saturation was 87% on 100% oxygen.", + "A chest X-ray was interpreted as a moderately large left-sided pneumothorax.", + "The CXR showed herniation of bowel into the left hemithorax.", + "A 14-gauge intravenous cannula was inserted into the second intercostal space along the mid-clavicular line.", + "Air, followed by approximately 900 ml of faecal fluid, was aspirated.", + "There was no improvement in the patient’s symptoms after needle decompression.", + "A repeat CXR showed a slight improvement of tracheal deviation.", + "There was further bowel herniation taking up most of the left lung field.", + "There was concern that the pneumothorax had not been completely relieved.", + "Arterial blood gas showed severe combined respiratory and metabolic acidosis.", + "Serum lactate levels were elevated at 3.2 mg dL-1.", + "The patient was transferred to the operating theatre for surgical intervention.", + "The surgical intervention was for left diaphragmatic rupture complicated by visceral herniation.", + "A repeated needle decompression or chest tube insertion prior to induction of anaesthesia was not attempted.", + "Rapid sequence induction was performed with cricoid pressure.", + "The lowest SpO2 obtained while the airway was being secured was 80%.", + "A left-sided double-lumen tube was inserted.", + "Both the tracheal and bronchial cuffs were inflated immediately prior to the commencement of one lung ventilation.", + "The position of the left bronchial cuff was confirmed to be in the left main bronchus with a fiberoptic scope.", + "The SpO2 improved to 100% after the double-lumen tube was inserted.", + "There was significant hypotension post-induction to lowest 63/45 mmHg.", + "Boluses of phenylephrine and adrenaline were administered.", + "An intraoperative 10 cm by 6 cm Bochdalek diaphragmatic hernia defect was found.", + "The herniation included the greater curve of the stomach, spleen, and long loop of transverse colon.", + "A large perforation with necrotic edges in the greater curve of the stomach was noted.", + "Feculent material was found in the pleural and peritoneal cavity.", + "The patient was aggressively fluid resuscitated with 1.8 litres of intravenous crystalloids.", + "Noradrenaline and adrenaline infusions were commenced shortly after induction.", + "The double-lumen tube was exchanged for a single-lumen tracheal tube.", + "The patient was sent to the Intensive Care Unit for continued resuscitation.", + "A repeat ABG at the conclusion of the surgery showed persistent combined respiratory and metabolic acidosis.", + "A relook surgery was performed on Day 3 of admission.", + "The hernia defect was repaired with a synthetic mesh.", + "The patient was extubated on Day 5 of admission.", + "He was discharged from the ICU on Day 6 of admission.", + "CXR on Day 6 of admission showed resolution of pneumothorax.", + "He was discharged home 22 days after admission." + ], + "summary": "A 23-year-old Chinese man initially presented with complaints of mild back pain and was discharged with symptomatic treatment. He presented again 3 days later, with dyspnea and left upper back pain and was haemodynamically unstable and hypoxic. A chest x-ray was reported as a moderately large left-sided pneumothorax with herniation of bowel into the left hemithorax. Needle decompression resulted in feculent fluid being aspirated with no resolution of symptoms. The patient required an immediate transfer to the operating theatre for surgical intervention of his left diaphragmatic rupture, complicated by visceral herniation and left tension pneumothorax, with accidental puncture of the herniated bowel. He underwent an emergent laparotomy with requirements for rapid lung isolation and continued aggressive resuscitation.", + "summary_subclaims": [ + "The patient is a 23-year-old Chinese man.", + "He initially presented with complaints of mild back pain.", + "He was discharged with symptomatic treatment.", + "He presented again 3 days later.", + "He had dyspnea and left upper back pain.", + "He was haemodynamically unstable.", + "He was hypoxic.", + "A chest x-ray was reported as a moderately large left-sided pneumothorax.", + "The chest x-ray showed herniation of bowel into the left hemithorax.", + "Needle decompression resulted in feculent fluid being aspirated.", + "Needle decompression did not result in resolution of symptoms.", + "The patient required an immediate transfer to the operating theatre.", + "The surgical intervention was for left diaphragmatic rupture.", + "The surgical intervention was complicated by visceral herniation.", + "The surgical intervention was complicated by left tension pneumothorax.", + "There was accidental puncture of the herniated bowel.", + "The patient underwent an emergent laparotomy.", + "There was a requirement for rapid lung isolation.", + "There was a requirement for continued aggressive resuscitation." + ] + }, + { + "id": "multiclinsum_test_3248_en.txt", + "fulltext": "A 62-year-old woman was referred to our department with complaints of low back and lower extremity pain for 2 years, 1.5 years after lumbar spine surgery, and recurrent low back pain for 1 year. The pain was dull and soreness, located in the lower back, accompanied by difficulty in turning over and radiating to the lower extremities. No numbness in the lower limbs has been previously reported. No apparent cause of the pain has been reported. The patient was treated at a local hospital and underwent L5/S1 discectomy with internal fixation in August 2019. Symptoms were relieved after surgery. However, low back pain recurred four months after the surgery. It was more severe on the left side, with soreness and cramp-like pain that worsened with changes in position and was insensitive to ibuprofen and codeine phosphate tablets. Non-contrast magnetic resonance imaging (MRI) of the lumbar spine was performed three months ago and showed a bulged lumbar intervertebral disc at the L3-L5 level.\n\nHer medical history included hypertension and diabetes. The blood pressure and glucose levels were well controlled, but the specific values did not contribute. She had undergone thyroid surgery eight years ago and continued to take levothyroxine sodium tablets (Euthyrox) after the operation. The patient had no family history of bone tumors.\n\nExamination revealed decreased lumbar mobility, straight leg raise (SLR) test (-), hip test (-), bilateral femoral nerve traction test (+), bilateral sacroiliac joint tenderness (+), bilateral T12-L3 paravertebral tenderness (+). Several questionnaires were used to assess patient status. The scoring results were as follows: numerical rating scale (NRS) 4 points in the resting state and 7 points when moving, ID-pain score 1 point, patient health questionnaire-9 (PHQ-9) 13 points, generalized anxiety disorder 7-item scale (GAD-7) 5 points, Patient Health questionnaire-15 (PHQ-15) 5 points.\n\nThe laboratory test results revealed elevated hs-CRP levels (28.3 mg/dL; normal range 0–8 mg/dL), and elevated erythrocyte sedimentation rate (49, 53, 67, 73, and 62 mm/h; normal range 0–20 mm/h). Results for serum autoantibodies, rheumatoid factor, and HLA-B27 were negative. All the other results were within the normal range. Lumbar computed tomography (CT) with three-dimensional reconstruction revealed postoperative changes in the L5-S1 vertebrae and intervertebral disc, narrowing of the intervertebral space, increased vertebral body density, and compressive changes in the L2 vertebrae. Lumbar noncontrast MRI revealed L5-S1 vertebrae fixation. The L3/4 intervertebral disc slightly bulged, L2 vertebral body compression changes and abnormal signal, and T11-L2 vertebrae abnormal signal. Sacroiliac joint CT showed high intensity in the left sacroiliac joint, which indicated osteitis of the left sacroiliac joint. Sacroiliac joint magnetic resonance imaging (MRI) revealed postoperative changes in the L5-S1 vertebrae.\n\nAdjacent segment degeneration (ASD) is a condition that often occurs after spinal fusion or when another back surgery is performed. Combined with the patient’s back surgery history and lumbar CT results, we first considered the possibility that the patient may have ASD. Symptomatic and supportive NSAIDs and nerve nutritional therapy were administered. Loxoprofen 60 mg TID, cobamamide 1.5 mg QD, calcium carbonate and vitamin D3 600 mg QD, and tromethamine 30 mg BID were given to the patient. However, the patient’s symptoms did not improve significantly. Therefore, we attempted to identify the other diagnoses.\n\nDuring re-examination, we found that her palms showed hyperkeratosis with active pustulosis. Combined with the previously elevated hs-CRP and erythrocyte sedimentation rate, we suspected that the patient had SAPHO syndrome and performed skeletal emission computed tomography (ECT). Skeletal ECT found a typical “horn sign” change on the sternum stem and revealed active bone metabolism of T8, T10, T11, L3, S1 vertebrae, bilateral sternoclavicular joints, bilateral sacroiliac joints, and bilateral knee joints, as well as increased bone density in some thoracic vertebrae.\n\nThe patient met the diagnostic criteria for SAPHO syndrome and was diagnosed with SAPHO syndrome. Based on the original treatment, we added sulfasalazine enteric-coated tablets 1 g BID, adalimumab 40 mg once a fortnight, pregabalin 75 mg BID, and tramadol sustained-release tablets 100 mg BID. The patient reported that her pain symptoms were significantly relieved. He was discharged from the hospital and received adalimumab treatment (40 mg once per fortnight in the first 6 months and 40 mg once per month after month 6) in the outpatient clinic. Patient compliance was good during the treatment, and no adverse reactions were reported. Hyperkeratosis with active pustulosis on both palms fully resolved after 12 months of treatment. The patient was followed up for 6 months after full recovery, and no recurrence was found in the symptoms of low back and lower extremity pain and palmar hyperkeratosis with active pustulosis.", + "fulltext_subclaims": [ + "The patient is a 62-year-old woman.", + "She had low back and lower extremity pain for 2 years.", + "The pain was dull and soreness.", + "The pain was located in the lower back.", + "The pain was accompanied by difficulty in turning over.", + "The pain radiated to the lower extremities.", + "No numbness in the lower limbs has been previously reported.", + "No apparent cause of the pain has been reported.", + "She underwent L5/S1 discectomy with internal fixation in August 2019.", + "Symptoms were relieved after surgery.", + "Low back pain recurred four months after the surgery.", + "The pain was more severe on the left side.", + "The pain was cramp-like.", + "The pain worsened with changes in position.", + "The pain was insensitive to ibuprofen and codeine phosphate tablets.", + "Non-contrast MRI of the lumbar spine showed a bulged lumbar intervertebral disc at the L3-L5 level.", + "Her medical history included hypertension.", + "Her medical history included diabetes.", + "She had undergone thyroid surgery eight years ago.", + "She continued to take levothyroxine sodium tablets after the operation.", + "She had no family history of bone tumors.", + "Examination revealed decreased lumbar mobility.", + "The straight leg raise test was negative.", + "The hip test was negative.", + "Bilateral femoral nerve traction test was positive.", + "Bilateral sacroiliac joint tenderness was positive.", + "Bilateral T12-L3 paravertebral tenderness was positive.", + "The NRS score was 4 points at rest.", + "The NRS score was 7 points when moving.", + "The ID-pain score was 1 point.", + "The PHQ-9 score was 13 points.", + "The GAD-7 score was 5 points.", + "The PHQ-15 score was 5 points.", + "hs-CRP was 28.3 mg/dL.", + "The erythrocyte sedimentation rate was 49, 53, 67, 73, and 62 mm/h.", + "Serum autoantibodies were negative.", + "Rheumatoid factor was negative.", + "HLA-B27 was negative.", + "Lumbar CT with three-dimensional reconstruction revealed postoperative changes in the L5-S1 vertebrae.", + "Lumbar CT showed narrowing of the intervertebral space.", + "Lumbar CT showed increased vertebral body density.", + "Lumbar CT showed compressive changes in the L2 vertebrae.", + "Lumbar noncontrast MRI revealed L5-S1 vertebrae fixation.", + "Lumbar noncontrast MRI showed L3/4 intervertebral disc slightly bulged.", + "Lumbar noncontrast MRI showed L2 vertebral body compression changes and abnormal signal.", + "Lumbar noncontrast MRI showed T11-L2 vertebrae abnormal signal.", + "Sacroiliac joint CT showed high intensity in the left sacroiliac joint.", + "Sacroiliac joint CT indicated osteitis of the left sacroiliac joint.", + "Sacroiliac joint MRI revealed postoperative changes in the L5-S1 vertebrae.", + "Adjacent segment degeneration is a condition that often occurs after spinal fusion.", + "We first considered the possibility that the patient may have adjacent segment degeneration.", + "Symptomatic and supportive NSAIDs and nerve nutritional therapy were administered.", + "Loxoprofen 60 mg TID was given.", + "Cobamamide 1.5 mg QD was given.", + "Calcium carbonate and vitamin D3 600 mg QD were given.", + "Tromethamine 30 mg BID was given.", + "The patient’s symptoms did not improve significantly.", + "Her palms showed hyperkeratosis with active pustulosis.", + "We suspected that the patient had SAPHO syndrome.", + "Skeletal ECT found a typical 'horn sign' change on the sternum stem.", + "Skeletal ECT revealed active bone metabolism of T8, T10, T11, L3, S1 vertebrae.", + "Skeletal ECT revealed active bone metabolism of bilateral sternoclavicular joints.", + "Skeletal ECT revealed active bone metabolism of bilateral sacroiliac joints.", + "Skeletal ECT revealed active bone metabolism of bilateral knee joints.", + "The patient met the diagnostic criteria for SAPHO syndrome.", + "She was diagnosed with SAPHO syndrome.", + "Sulfasalazine enteric-coated tablets 1 g BID were added.", + "Adalimumab 40 mg once a fortnight was added.", + "Pregabalin 75 mg BID was added.", + "Tramadol sustained-release tablets 100 mg BID were added.", + "The patient reported significant relief of pain symptoms.", + "She received adalimumab treatment (40 mg once per fortnight in the first 6 months and 40 mg once per month after month 6).", + "Patient compliance was good during the treatment.", + "No adverse reactions were reported.", + "Hyperkeratosis with active pustulosis on both palms fully resolved after 12 months of treatment.", + "The patient was followed up for 6 months after full recovery.", + "No recurrence was found in the symptoms of low back and lower extremity pain.", + "No recurrence was found in the symptoms of palmar hyperkeratosis with active pustulosis." + ], + "summary": "A 62-year-old woman was referred to our department with complaints of low back and lower extremity pain for 2 years, 1.5 years after lumbar spine surgery, and recurrent low back pain for 1 year. Laboratory test results revealed elevated hs-CRP levels and erythrocyte sedimentation rate. Combined with her surgical history and lumbar CT results, adjacent segment degeneration (ASD) was first considered. NSAIDs, analgesics, and supplemental therapies were also administered. However, the patient's symptoms were not significantly relieved. During re-examination, hyperkeratosis with active pustulosis was observed on the patient's palms. Osteitis of the left sacroiliac joint was revealed on imaging. Skeletal ECT revealed a typical \"horn sign\". The patient was diagnosed with SAPHO syndrome. Based on the original treatment, sulfasalazine enteric-coated tablets, adalimumab (a biological agent of TNF-α), pregabalin, and tramadol sustained-release tablets were administered. The patient reported that her pain was significantly relieved. He was discharged from the hospital and received adalimumab treatment (40 mg once per fortnight in the first 6 months and 40 mg once per month after month 6) in the outpatient clinic. The hyperkeratosis with active pustulosis on both palms fully recovered after 12 months of treatment. The patient was followed up 6 months after full recovery, and no recurrence was found in the symptoms of low back and lower extremity pain and palmar hyperkeratosis with active pustulosis.", + "summary_subclaims": [ + "The patient is a 62-year-old woman.", + "She had complaints of low back and lower extremity pain for 2 years.", + "The pain began 1.5 years after lumbar spine surgery.", + "She had recurrent low back pain for 1 year.", + "Laboratory test results revealed elevated hs-CRP levels.", + "Laboratory test results revealed elevated erythrocyte sedimentation rate.", + "Adjacent segment degeneration (ASD) was first considered.", + "NSAIDs, analgesics, and supplemental therapies were administered.", + "The patient's symptoms were not significantly relieved.", + "Hyperkeratosis with active pustulosis was observed on the patient's palms.", + "Osteitis of the left sacroiliac joint was revealed on imaging.", + "Skeletal ECT revealed a typical 'horn sign'.", + "The patient was diagnosed with SAPHO syndrome.", + "Sulfasalazine enteric-coated tablets were administered.", + "Adalimumab was administered.", + "Pregabalin was administered.", + "Tramadol sustained-release tablets were administered.", + "The patient reported that her pain was significantly relieved.", + "The patient was discharged from the hospital.", + "Adalimumab treatment was 40 mg once per fortnight in the first 6 months.", + "Adalimumab treatment was 40 mg once per month after month 6.", + "The hyperkeratosis with active pustulosis on both palms fully recovered after 12 months of treatment.", + "The patient was followed up 6 months after full recovery.", + "No recurrence was found in the symptoms of low back and lower extremity pain.", + "No recurrence was found in the symptoms of palmar hyperkeratosis with active pustulosis." + ] + }, + { + "id": "multiclinsum_test_2721_en.txt", + "fulltext": "A 59-year-old lady with a BMI of 27 kg/m2 and no comorbid underwent an open appendicectomy via a Lanz incision for perforated appendicitis. There was a superficial surgical site infection which was treated by dressing followed by secondary suturing. Three years later, she presented to us with an incarcerated incisional hernia. We performed a laparoscopic intraperitoneal onlay mesh (IPOM) repair for her. Intraoperatively, standard port placement was done, followed by adhesiolysis of small bowel segments from the hernia sac. The fascial defect measures 6 cm in the largest dimension . Prior to the mesh fixation, primary fascial closure was done using non-absorbable sutures (Prolene® 0) passed extra-corporeally with the help of an intravenous cannula BD Angiocath™ (14 gauge) instead of a transfascial suture passer. The rest of the procedural steps were the same as a standard laparoscopic IPOM repair. Post-operative recovery was uneventful, and during her follow-up six months later, she has no hernia recurrence or chronic pain.", + "fulltext_subclaims": [ + "The patient is a 59-year-old lady.", + "The patient had a BMI of 27 kg/m2.", + "The patient had no comorbidities.", + "The patient underwent an open appendicectomy via a Lanz incision.", + "The appendicectomy was performed for perforated appendicitis.", + "There was a superficial surgical site infection.", + "The infection was treated by dressing.", + "The infection was treated followed by secondary suturing.", + "Three years later, she presented with an incarcerated incisional hernia.", + "A laparoscopic intraperitoneal onlay mesh (IPOM) repair was performed.", + "Intraoperatively, standard port placement was done.", + "Adhesiolysis of small bowel segments from the hernia sac was performed.", + "The fascial defect measures 6 cm in the largest dimension.", + "Prior to the mesh fixation, primary fascial closure was done using non-absorbable sutures (Prolene® 0).", + "The sutures were passed extra-corporeally with the help of an intravenous cannula BD Angiocath™ (14 gauge).", + "The rest of the procedural steps were the same as a standard laparoscopic IPOM repair.", + "Post-operative recovery was uneventful.", + "During follow-up six months later, she has no hernia recurrence.", + "During follow-up six months later, she has no chronic pain." + ], + "summary": "We present here a novel technique of using intravenous (IV) cannula as an alternative to suture passer for fascial closure during laparoscopic IPOM repair for a 59-year-old patient with an incisional ventral hernia. The placement of non-absorbable sutures for fascial closure was done with the help of a 14 gauge IV cannula instead of a transfascial suture passer. The rest of the procedural steps were the same as a standard laparoscopic IPOM repair. The patient's post-operative recovery was uneventful.", + "summary_subclaims": [ + "A 59-year-old patient with an incisional ventral hernia underwent laparoscopic IPOM repair.", + "A novel technique of using an intravenous cannula as an alternative to a suture passer was used for fascial closure.", + "The placement of non-absorbable sutures for fascial closure was done with the help of a 14 gauge IV cannula.", + "The rest of the procedural steps were the same as a standard laparoscopic IPOM repair.", + "The patient's post-operative recovery was uneventful." + ] + }, + { + "id": "multiclinsum_test_1236_en.txt", + "fulltext": "A total laryngectomized 72-year-old male was admitted with a complaint of difficulty in swallowing the foods and intractable liquid leakage from the valve of the tracheoesophageal prosthesis. The examination revealed a prosthesis covered with crust and dry mucus. Patient history was obtained from medical records and it was revealed that he had been using the same voice prosthesis smoothly for 17 years without changing. In fact, he had no significant complication in this period. However, he had been experiencing some difficulties in swallowing and leakage around the valve for a year. In addition, he had a serious iatrophobia and refused the change of prosthesis for several times.\nHe was questioned for his daily habits which might help to preserve the prosthesis for a long time Tracheoesophageal fistula construction was performed after total laryngectomy for voice and speech restoration. Furthermore, flexible fiber optic esophagoscopy was performed to evaluate the fistula in case of a lesion; however, no lesion was detected on the esophageal mucosa . The patient was referred to a psychologist to make him convinced regarding the prosthesis change. After the removal of the old prosthesis , a new voice prosthesis (20-F,16 mm) was inserted and no complication occurred.", + "fulltext_subclaims": [ + "A total laryngectomized 72-year-old male was admitted with a complaint of difficulty in swallowing the foods and intractable liquid leakage from the valve of the tracheoesophageal prosthesis.", + "The examination revealed a prosthesis covered with crust and dry mucus.", + "Patient history was obtained from medical records.", + "It was revealed that he had been using the same voice prosthesis smoothly for 17 years without changing.", + "He had no significant complication in this period.", + "He had been experiencing some difficulties in swallowing and leakage around the valve for a year.", + "He had a serious iatrophobia and refused the change of prosthesis for several times.", + "Tracheoesophageal fistula construction was performed after total laryngectomy for voice and speech restoration.", + "Flexible fiber optic esophagoscopy was performed to evaluate the fistula in case of a lesion.", + "No lesion was detected on the esophageal mucosa.", + "The patient was referred to a psychologist to make him convinced regarding the prosthesis change.", + "After the removal of the old prosthesis, a new voice prosthesis (20-F,16 mm) was inserted.", + "No complication occurred." + ], + "summary": "A 72-year-old patient with total laryngectomy and tracheoesophageal voice prosthesis (VP) presented our voice clinic with difficulty in swallowing and leakage around the valve of VP. In this report, we aim to present the patient who has used a single voice prosthesis for 17 years without a complication.", + "summary_subclaims": [ + "The patient is a 72-year-old individual.", + "The patient has a total laryngectomy.", + "The patient has a tracheoesophageal voice prosthesis.", + "The patient presented with difficulty in swallowing.", + "The patient reported leakage around the valve of the voice prosthesis.", + "The patient has used a single voice prosthesis for 17 years.", + "The patient has used the voice prosthesis without a complication." + ] + }, + { + "id": "multiclinsum_test_2469_en.txt", + "fulltext": "A 64-year-old Indian man was referred with complaints of abdominal pain, vomiting and not passing flatus or feces for four days. Our patient's general condition was poor; he was febrile, with a pulse rate of 124/minute and blood pressure 90 mm/Hg. X-rays of his abdomen showed multiple air fluid levels suggestive of acute intestinal obstruction. With the provisional diagnosis of acute abdomen (acute intestinal obstruction) our patient was resuscitated and sent for an urgent laparotomy. On exploration, our patient had severely dilated small gut loops with the terminal ileal loop twisted around the omental band and adherent to his left pelvic wall. On releasing the omental band, the ileal loop was dissected free from his left pelvic wall. Once the loops had been released, we found a large, white, oval shaped, extra-luminal body in the region of his sigmoid colon . The body was soft to firm in consistency (resembling a boiled hen's egg) and attached (parasitized) to the omentum . In addition, part of the appendices epiploicae, attached to his sigmoid colon, were calcified with constricted stalks. The peritoneal loose body was largely parasitized to the omentum with a separate feeding vessel supplying it from the omentum.\nThe body was an oval shaped mass, measuring 7 cm in length and 5 cm in width, and weighed 74 g. On the cut surface, it had classic appearance like a boiled egg, with a distinct white peripheral part and yellow central part . The white part was smooth and soft in consistency while the central yellow part was slightly firm in the periphery and hard (calcified) at the central point. The surfaces were smooth and shiny. On histological examination, it consisted of laminated strands of a fibrinoid substance with a large amount of proteinaceous material in the peripheral white part (boiled albumin with a high collagen deposition) and saponified fat with calcification in the central yellow part.\nOur patient did well post-operatively; he resumed his oral diet on the third post-operative day. He was discharged from the hospital five days after the operation.", + "fulltext_subclaims": [ + "The patient was a 64-year-old Indian man.", + "He had complaints of abdominal pain, vomiting, and not passing flatus or feces for four days.", + "The patient's general condition was poor.", + "He was febrile.", + "His pulse rate was 124/minute.", + "His blood pressure was 90 mm/Hg.", + "X-rays of the abdomen showed multiple air fluid levels.", + "The X-rays were suggestive of acute intestinal obstruction.", + "The provisional diagnosis was acute abdomen (acute intestinal obstruction).", + "The patient was resuscitated.", + "The patient was sent for an urgent laparotomy.", + "On exploration, the patient had severely dilated small gut loops.", + "The terminal ileal loop was twisted around the omental band.", + "The ileal loop was adherent to the left pelvic wall.", + "On releasing the omental band, the ileal loop was dissected free from the left pelvic wall.", + "A large, white, oval shaped, extra-luminal body was found in the region of the sigmoid colon.", + "The body was soft to firm in consistency.", + "The body resembled a boiled hen's egg.", + "The body was attached to the omentum.", + "Part of the appendices epiploicae attached to the sigmoid colon were calcified.", + "The stalks of the calcified appendices epiploicae were constricted.", + "The peritoneal loose body was largely parasitized to the omentum.", + "The body had a separate feeding vessel supplying it from the omentum.", + "The body measured 7 cm in length and 5 cm in width.", + "The body weighed 74 g.", + "On the cut surface, it had a classic appearance like a boiled egg.", + "The white peripheral part was smooth and soft in consistency.", + "The central yellow part was slightly firm in the periphery.", + "The central yellow part was hard (calcified) at the central point.", + "The surfaces were smooth and shiny.", + "Histological examination showed laminated strands of a fibrinoid substance.", + "The peripheral white part contained a large amount of proteinaceous material.", + "The peripheral white part resembled boiled albumin with high collagen deposition.", + "The central yellow part contained saponified fat with calcification.", + "The patient did well post-operatively.", + "He resumed his oral diet on the third post-operative day.", + "He was discharged from the hospital five days after the operation." + ], + "summary": "We report a case of a giant loose peritoneal body measuring 7 × 5 cm found incidentally in a 64-year-old Indian man who presented with acute intestinal obstruction. We present the current hypothesis and our opinion on the genesis of such large bodies and discuss the problems in diagnosis.", + "summary_subclaims": [ + "A giant loose peritoneal body measuring 7 × 5 cm was found incidentally in a 64-year-old Indian man.", + "The patient presented with acute intestinal obstruction.", + "The current hypothesis and opinion on the genesis of such large bodies are presented.", + "The problems in diagnosis are discussed." + ] + }, + { + "id": "multiclinsum_test_570_en.txt", + "fulltext": "A 28-year-old male presented with a chronic dry cough and weight loss of 1-year duration, and 2 months of worsening mid-thoracic back pain accompanied by bilateral lower extremity weakness. Notably, there were no known TB exposure, recent travel, smoking, or history of intravenous drug use. On the initial physical examination, he had bilateral rales and left lower extremity weakness (4/5).\nMagnetic resonance imaging revealed an epidural collection causing compression of the spinal cord from T5 to T6; this was accompanied by a moderate-sized, left-sided pleural effusion, a left lingular/lower lobe consolidation, and multiple cavitary lesions in the right lung [-]. The patient was initially diagnosed with pulmonary TB/Pott’s disease and myelopathy, resulting in the standard TB regimen of rifampin, isoniazid, pyrazinamide, and ethambutol.\nSurgery included a T5-T6 decompression (e.g., costotransversectomy); the largely ventral mass (e.g., anterior to the cord) was removed. This was followed by open reduction and a posterior T4-T8 fusion.\nA 1.2 cm × 0.9 cm × 0.6 cm bone tissue fragment from the T6 lamina and 3.0 cm × 2.0 cm × 1.0 cm aggregate from the T6 epidural tissue demonstrated metastatic adenocarcinoma, likely primary from the lung.\nThe patient’s postoperative course was complicated by an inability to be weaned off the ventilator; the high oxygen requirements were attributed to the left lung disease. A chest radiograph performed the day of surgery demonstrated an enlarging left pleural effusion and a left pneumothorax. There were also patchy right perihilar airspace opacities/scattered nodules, considered infectious/inflammatory . The patient subsequently experienced acute hypoxemic respiratory failure, acute respiratory distress syndrome, shock, and cardiac arrest. Of interest, the TB polymerase chain reaction came back negative.", + "fulltext_subclaims": [ + "The patient is a 28-year-old male.", + "The patient had a chronic dry cough and weight loss of 1-year duration.", + "The patient had 2 months of worsening mid-thoracic back pain.", + "The patient had bilateral lower extremity weakness.", + "There were no known TB exposures.", + "There was no recent travel.", + "There was no history of intravenous drug use.", + "On initial physical examination, the patient had bilateral rales.", + "On initial physical examination, the patient had left lower extremity weakness (4/5).", + "Magnetic resonance imaging revealed an epidural collection causing compression of the spinal cord from T5 to T6.", + "Magnetic resonance imaging showed a moderate-sized, left-sided pleural effusion.", + "Magnetic resonance imaging showed a left lingular/lower lobe consolidation.", + "Magnetic resonance imaging showed multiple cavitary lesions in the right lung.", + "The patient was initially diagnosed with pulmonary TB/Pott’s disease and myelopathy.", + "The patient was started on a standard TB regimen of rifampin, isoniazid, pyrazinamide, and ethambutol.", + "Surgery included a T5-T6 decompression.", + "Surgery included removal of a largely ventral mass anterior to the cord.", + "Surgery included open reduction and a posterior T4-T8 fusion.", + "A 1.2 cm × 0.9 cm × 0.6 cm bone tissue fragment from the T6 lamina demonstrated metastatic adenocarcinoma.", + "A 3.0 cm × 2.0 cm × 1.0 cm aggregate from the T6 epidural tissue demonstrated metastatic adenocarcinoma.", + "The metastatic adenocarcinoma was likely primary from the lung.", + "The patient’s postoperative course was complicated by an inability to be weaned off the ventilator.", + "The high oxygen requirements were attributed to the left lung disease.", + "A chest radiograph performed the day of surgery demonstrated an enlarging left pleural effusion.", + "A chest radiograph performed the day of surgery demonstrated a left pneumothorax.", + "There were patchy right perihilar airspace opacities.", + "There were scattered nodules considered infectious/inflammatory.", + "The patient subsequently experienced acute hypoxemic respiratory failure.", + "The patient subsequently experienced acute respiratory distress syndrome.", + "The patient subsequently experienced shock.", + "The patient subsequently experienced cardiac arrest.", + "The TB polymerase chain reaction came back negative." + ], + "summary": "A 28-year-old male presented with a chronic dry cough, weight loss, and 2 months of increased back pain accompanied by bilateral lower extremity weakness. Magnetic resonance imaging revealed an epidural collection causing compression of the spinal cord at the T5-T6 level. The initial diagnosis was Mycobacterium tuberculosis/Pott's disease. A thoracic T4-T8 decompression fusion was performed; however, pathologic examination of the tissue revealed adenocarcinoma. Postoperatively, after the patient experienced several episodes of acute respiratory distress and a tension pneumothorax, lung imaging confirmed multiple tumor infiltrates along with lung cancer extending into the thoracic vertebrae. Pelvic studies also confirmed the presence of pelvic metastases. The patient passed away 3 weeks following surgery.", + "summary_subclaims": [ + "The patient was a 28-year-old male.", + "The patient had a chronic dry cough.", + "The patient had weight loss.", + "The patient had 2 months of increased back pain.", + "The patient had bilateral lower extremity weakness.", + "Magnetic resonance imaging revealed an epidural collection.", + "The epidural collection was causing compression of the spinal cord at the T5-T6 level.", + "The initial diagnosis was Mycobacterium tuberculosis/Pott's disease.", + "A thoracic T4-T8 decompression fusion was performed.", + "Pathologic examination of the tissue revealed adenocarcinoma.", + "Postoperatively, the patient experienced several episodes of acute respiratory distress.", + "Postoperatively, the patient had a tension pneumothorax.", + "Lung imaging confirmed multiple tumor infiltrates.", + "Lung cancer extended into the thoracic vertebrae.", + "Pelvic studies confirmed the presence of pelvic metastases.", + "The patient passed away 3 weeks following surgery." + ] + }, + { + "id": "multiclinsum_test_1901_en.txt", + "fulltext": "A 43 year old female district nurse presented to the accident and emergency department with a 6 hour history of initially generalized abdominal pain which was localizing to the right. This was associated with nausea and loss of appetite, made worse by movement and not relieved with intramuscular morphine injection. There was no history of recent or past trauma to the chest or abdomen. On examination, she was tender in the right upper quadrant and right iliac fossa with rebound and guarding, with a Rovsing positive sign and normal bowel sounds. She was incidentally found to have some marfanoid features including the long span of upper limbs, a high arched palate and the very soft early diastolic murmur of aortic regurgitation. The patient had a positive family history of Marfan's syndrome but had never undergone genetic testing to confirm the diagnosis.\nA likely diagnosis of appendicitis was made on the clinical picture associated with a pyrexia and raised white cell count and C – reactive protein. Her abdominal X-ray at that time showed absence of gas in the right side of her bowel. Her chest X-ray did not show any obvious abnormality She was taken to theatre the same day for appendicectomy through a standard right iliac fossa incision. There was a small amount of free fluid but the right iliac fossa was filled with a normal looking gall bladder and small bowel only with no sign of the caecum, appendix, ascending or proximal transverse colon. The terminal ileum was found to run up under the right lobe of the liver towards the hilum. The right iliac fossa wound was closed and we proceeded to an exploratory laparoscopy.\nAt laparoscopy, the liver was retracted to see under the right liver lobe. The proximal transverse colon was found to be running up towards the liver hilum were it felt to be tethered. This suggested a possible herniation of the right colon into the chest. The procedure was abandoned and a CT thorax and abdomen were performed to define the anatomy involved.\nThis demonstrated bilateral pleural effusions of moderate size with underlying unexpanded lungs. The liver had what appeared to be a large Reidl's lobe. Behind the right liver lobe, the right kidney was markedly elevated and the ileo-caecal junction appeared to lie between the liver and the kidney. The right side of the colon appeared to lie above the liver. Three dimensional reconstruction of the scans demonstrated absence of the right hemidiaphragm. The symptoms and signs persisted and a laparotomy was performed. At laparotomy, there was some free fluid. There was definitely a large defect in the right hemidiaphragm. The right liver lobe had grown right up into the right intrathoracic space. There was a large hernial sac beneath the right lobe of the liver between the common bile duct, duodenum and liver, displacing the right kidney medially and containing transverse colon, terminal ileum, caecum, appendix and free fluid. The contents of this sac were successfully reduced and a perforated gangrenous appendix with pus was found within the intrathoracic hernial sac. A standard appendicectomy was performed. The right colon was formally mobilized, fully reduced and the caecum was fixed within the right iliac fossa.\nThe patient was admitted to the intensive care unit postoperatively where she made a good recovery. She had instant relief of her abdominal symptoms and post-operative contrast study demonstrated the presence of the right colon within the abdomen . She was discharged a week post-operatively.", + "fulltext_subclaims": [ + "The patient is a 43 year old female district nurse.", + "She presented with a 6 hour history of initially generalized abdominal pain localizing to the right.", + "The pain was associated with nausea and loss of appetite.", + "The pain was made worse by movement.", + "The pain was not relieved with intramuscular morphine injection.", + "There was no history of recent or past trauma to the chest or abdomen.", + "On examination, she was tender in the right upper quadrant.", + "On examination, she was tender in the right iliac fossa.", + "Rebound tenderness was present.", + "Guarding was present.", + "The Rovsing sign was positive.", + "Bowel sounds were normal.", + "She was incidentally found to have marfanoid features.", + "She had a positive family history of Marfan's syndrome.", + "She had never undergone genetic testing to confirm the diagnosis.", + "A likely diagnosis of appendicitis was made.", + "The diagnosis was based on the clinical picture.", + "The diagnosis was associated with pyrexia.", + "The diagnosis was associated with a raised white cell count.", + "The diagnosis was associated with a raised C-reactive protein.", + "Her abdominal X-ray showed absence of gas in the right side of her bowel.", + "Her chest X-ray did not show any obvious abnormality.", + "She was taken to theatre the same day for appendicectomy.", + "The appendicectomy was performed through a standard right iliac fossa incision.", + "There was a small amount of free fluid.", + "The right iliac fossa was filled with a normal looking gall bladder.", + "The right iliac fossa was filled with small bowel.", + "There was no sign of the caecum.", + "There was no sign of the appendix.", + "There was no sign of the ascending colon.", + "There was no sign of the proximal transverse colon.", + "The terminal ileum was found to run up under the right lobe of the liver towards the hilum.", + "An exploratory laparoscopy was performed.", + "At laparoscopy, the proximal transverse colon was found to be running up towards the liver hilum.", + "The proximal transverse colon was felt to be tethered.", + "This suggested a possible herniation of the right colon into the chest.", + "The procedure was abandoned.", + "A CT thorax and abdomen were performed.", + "The CT demonstrated bilateral pleural effusions of moderate size.", + "The CT demonstrated unexpanded lungs.", + "The liver had what appeared to be a large Reidl's lobe.", + "The right kidney was markedly elevated.", + "The ileo-caecal junction appeared to lie between the liver and the kidney.", + "The right side of the colon appeared to lie above the liver.", + "Three dimensional reconstruction demonstrated absence of the right hemidiaphragm.", + "A laparotomy was performed.", + "There was a large defect in the right hemidiaphragm.", + "The right liver lobe had grown into the right intrathoracic space.", + "There was a large hernial sac beneath the right lobe of the liver.", + "The hernial sac was between the common bile duct, duodenum, and liver.", + "The hernial sac displaced the right kidney medially.", + "The hernial sac contained transverse colon.", + "The hernial sac contained terminal ileum.", + "The hernial sac contained caecum.", + "The hernial sac contained appendix.", + "The hernial sac contained free fluid.", + "A perforated gangrenous appendix with pus was found within the intrathoracic hernial sac.", + "A standard appendicectomy was performed.", + "The right colon was formally mobilized.", + "The right colon was fully reduced.", + "The caecum was fixed within the right iliac fossa.", + "The patient was admitted to the intensive care unit postoperatively.", + "She made a good recovery.", + "She had instant relief of her abdominal symptoms.", + "A post-operative contrast study demonstrated the presence of the right colon within the abdomen.", + "She was discharged a week post-operatively." + ], + "summary": "A 43 year old woman was admitted with classical appendicitis requiring surgery. She incidentally had Marfan's clinical features with a positive family history for the syndrome. At operation she had grossly abnormal abdominal anatomy. Radiological investigations demonstrated a large right congenital diaphragmatic hernia with an intrathoracic hernial sac containing a perforated gangrenous appendix. The hernial sac was opened surgically and the appendix excised. The patient made a full recovery.", + "summary_subclaims": [ + "A 43 year old woman was admitted with classical appendicitis requiring surgery.", + "She incidentally had Marfan's clinical features.", + "She had a positive family history for Marfan's syndrome.", + "At operation she had grossly abnormal abdominal anatomy.", + "Radiological investigations demonstrated a large right congenital diaphragmatic hernia.", + "The hernial sac contained a perforated gangrenous appendix.", + "The hernial sac was opened surgically.", + "The appendix was excised.", + "The patient made a full recovery." + ] + }, + { + "id": "multiclinsum_test_2335_en.txt", + "fulltext": "The patient was a 16-year-old female with a past medical history of type 1 diabetes on insulin pump therapy, previous episodes of DKA, and autoimmune hypothyroidism. She presented to the emergency department with altered mental status, severe abdominal pain, and multiple episodes of vomiting. According to her mother, all her symptoms started within the prior 24 hours. The patient was observed to be awake but disoriented with generalized abdominal tenderness to palpation. The insulin pump was taken off by the family just prior to presenting to the hospital. She presented to the hospital via emergency medical services, and her vital signs were normal upon arrival. Initial physical examination revealed a Glasgow Coma Scale (GCS) of 12 (eyes 3, verbal 4, motor 5) and the patient was localizing to pain on palpation of the right lower quadrant, without any other significant exam findings. Monitoring and intravenous (IV) access were established, and blood for laboratory evaluation was collected.\nThe patient was started on a lactated Ringer’s infusion. Her vital signs remained stable and upon re-evaluation, her GCS remained unchanged. With her clinical picture and previous history with DKA, initial concern was for DKA, although her initial point-of-care glucose was 109 mg/dL (reference 80–140 mg/dL) Subsequent point-of-care glucose readings showed decreasing levels less than 100 mg/dL (80–140 mg/dl) requiring glucose administration. Because of initial normal point-of-care glucose readings, the treating team pursued other causes of altered mental status. Initial labs were significant for a venous pH of 7.2 (7.35–7.45), bicarbonate of 8 mEq/L (21–28 mEq/L); anion gap of 33 millimoles per liter (mmol/L) (4–12 mmol/L); lactate of 2 mmol/L (0.5–1 mmol/L); sodium 133 mEq/L (135–145 mEq/L); potassium 4.9 mEq/L (3.6–5.2 mEq/L); blood urea nitrogen 19 mg/dL (7–20 mg/dL); creatinine of 0.8 mg/dL (0.84–1.21 mg/dL); beta-hydroxybutyrate of 3.26 mmol/L (0.4–0.5 mmol/L); initial plasma glucose of 108 mg/dL (80–140/mg/dL); and leukocytosis of 20,600 per microliter (4500–11000 per microliter).\nUrine toxicology, salicylate, and acetaminophen screen and pregnancy test were negative. A non-contrast computed tomography (CT) of the brain was unremarkable. She also had an IV contrast-enhanced CT of the abdomen, which was suspicious for possible early appendicitis. With her resulting labs, other causes of elevated gap metabolic acidosis were considered. An endocrine consult was obtained for possible eDKA. Based on the consult and test results, the patient was started on an insulin drip at 0.1units per kilogram per hour as well as an infusion of a dextrose 10% solution.\nPediatric surgery was consulted, and after exam and review of the CT results recommended that the patient be taken to the operating room for an appendectomy. Surgical findings were noted to be equivocal and the appendix was removed without complication. The patient’s mental status improved post appendectomy. With fluid and insulin therapy her condition improved, laboratory abnormalities normalized within a few days, and she was subsequently discharged home. The consulting teams agreed that the final diagnosis was eDKA likely caused by appendicitis.", + "fulltext_subclaims": [ + "The patient was a 16-year-old female.", + "She had a past medical history of type 1 diabetes.", + "She was on insulin pump therapy.", + "She had previous episodes of DKA.", + "She had autoimmune hypothyroidism.", + "She presented to the emergency department with altered mental status.", + "She had severe abdominal pain.", + "She had multiple episodes of vomiting.", + "According to her mother, all her symptoms started within the prior 24 hours.", + "The patient was observed to be awake but disoriented.", + "She had generalized abdominal tenderness to palpation.", + "The insulin pump was taken off by the family just prior to presenting to the hospital.", + "She presented to the hospital via emergency medical services.", + "Her vital signs were normal upon arrival.", + "Initial physical examination revealed a Glasgow Coma Scale (GCS) of 12.", + "The patient was localizing to pain on palpation of the right lower quadrant.", + "Monitoring and intravenous (IV) access were established.", + "Blood for laboratory evaluation was collected.", + "The patient was started on a lactated Ringer’s infusion.", + "Her vital signs remained stable.", + "Upon re-evaluation, her GCS remained unchanged.", + "Initial concern was for DKA.", + "Her initial point-of-care glucose was 109 mg/dL.", + "Subsequent point-of-care glucose readings showed decreasing levels less than 100 mg/dL.", + "Because of initial normal point-of-care glucose readings, the treating team pursued other causes of altered mental status.", + "Initial labs were significant for a venous pH of 7.2.", + "Initial labs were significant for a bicarbonate of 8 mEq/L.", + "Initial labs were significant for an anion gap of 33 mmol/L.", + "Initial labs were significant for a lactate of 2 mmol/L.", + "Initial labs were significant for a beta-hydroxybutyrate of 3.26 mmol/L.", + "Initial labs were significant for a plasma glucose of 108 mg/dL.", + "Initial labs were significant for a leukocytosis of 20,600 per microliter.", + "Urine toxicology was negative.", + "A non-contrast computed tomography (CT) of the brain was unremarkable.", + "An IV contrast-enhanced CT of the abdomen was suspicious for possible early appendicitis.", + "An endocrine consult was obtained for possible eDKA.", + "The patient was started on an insulin drip at 0.1 units per kilogram per hour.", + "The patient was started on an infusion of a dextrose 10% solution.", + "Pediatric surgery was consulted.", + "Surgical findings were noted to be equivocal.", + "The appendix was removed without complication.", + "The patient’s mental status improved post appendectomy.", + "Her condition improved with fluid and insulin therapy.", + "Laboratory abnormalities normalized within a few days.", + "The consulting teams agreed that the final diagnosis was eDKA likely caused by appendicitis." + ], + "summary": "A 16-year-old female with a past medical history of type 1 diabetes presented to the emergency department with altered mental status, vomiting, and abdominal pain. She was diagnosed with euglycemic diabetic ketoacidosis.", + "summary_subclaims": [ + "The patient is a 16-year-old female.", + "The patient has a past medical history of type 1 diabetes.", + "The patient presented to the emergency department with altered mental status.", + "The patient presented to the emergency department with vomiting.", + "The patient presented to the emergency department with abdominal pain.", + "The patient was diagnosed with euglycemic diabetic ketoacidosis." + ] + }, + { + "id": "multiclinsum_test_3313_en.txt", + "fulltext": "The patient was a 60-year-old woman who had been experiencing repeated loss of consciousness for over 20 years. Before the onset, there were obvious causes such as eating irritating food, defecation and fatigue. Electrocardiograms, holter electrocardiograms, and head-up tilt test were all normal for the patient in the hospital. She has no history of cardiovascular diseases.\n\nUpon admission, the patient presented with a heart rate of 55 beats/min and a blood pressure of 140/90mmHg. Physical and laboratory tests revealed no obvious abnormalities, and the electrocardiogram showed sinus bradycardia. Echocardiography indicated mild aortic valve insufficiency, with the rest of the heart structure and function appearing normal. A lung CT scan revealed a few micronodules in both lungs, while a craniocerebral CT scan showed no significant abnormalities.\n\nGiven the patient���s history of syncope episodes occurring after the consumption of spicy foods such as hot peppers, it was hypothesized that the syncope might be related to this. Despite several upright tilt tests yielding no positive findings, with informed consent, a “chili pepper stimulation” experiment was conducted on the patient. During the experiment, it was observed that the patient’s blood pressure before consuming the pepper was 125/83mmHg, and the heart rate was 73 beats per minute. After consuming the pepper for 5 minutes, the patient experienced nausea and dizziness, followed by a gradual drop in heart rate to 37 beats/min and a drop in blood pressure to 56/37 mmHg, along with cold limbs and foggy consciousness. The patient was promptly administered atropine, dopamine, and continuous fluid rehydration, leading to a gradual recovery of blood pressure to 150/80mmHg and a heart rate of 90 beats/min. Based on the patient’s history and attack characteristics, the initial diagnosis was VVS.\n\nDespite unsuccessful medical interventions, the patient’s quality of life had been significantly impacted by recurrent syncope episodes. Consequently, a decision was made to proceed with the ablation of the cardioneuroablation. A cardiac electrophysiological study was performed before surgery. As a result, the sinoatrial conduction time, sinus node recovery time, and effective refractory period of the atrioventricular node were all normal for the patient. During ablation, we observed a decrease in heart rate and sinus arrest due to the vagus response caused by radiofrequency energy delivery to the left upper ganglion plexus. Following ventricular pacing protection, there was a notable increase in sinus heart rate subsequent to anatomic ablation at specific locations, including the left superior GP (LSGP; located in the superolateral area around the root of the left superior pulmonary vein), left inferior GP (LIGP; located in the inferoposterior area around the root of the left inferior pulmonary vein), right inferior GP (RIGP; located in the inferoposterior area around the root of the right inferior pulmonary vein), right anterior GP (RAGP; located in the superior-anterior area around the root of the right superior pulmonary vein). Pepper stimulation did not induce arrhythmia after surgery, and head-up tilt testing did not reveal any abnormality. Subsequent to a one-year follow-up, the patient remained asymptomatic.", + "fulltext_subclaims": [ + "The patient was a 60-year-old woman.", + "She had been experiencing repeated loss of consciousness for over 20 years.", + "Before the onset, there were obvious causes such as eating irritating food, defecation and fatigue.", + "Electrocardiograms, holter electrocardiograms, and head-up tilt test were all normal for the patient in the hospital.", + "She has no history of cardiovascular diseases.", + "Upon admission, the patient presented with a heart rate of 55 beats/min and a blood pressure of 140/90mmHg.", + "Physical and laboratory tests revealed no obvious abnormalities.", + "The electrocardiogram showed sinus bradycardia.", + "Echocardiography indicated mild aortic valve insufficiency.", + "The rest of the heart structure and function appeared normal.", + "A lung CT scan revealed a few micronodules in both lungs.", + "A craniocerebral CT scan showed no significant abnormalities.", + "The patient’s history of syncope episodes occurring after the consumption of spicy foods such as hot peppers was noted.", + "It was hypothesized that the syncope might be related to this.", + "Despite several upright tilt tests yielding no positive findings, with informed consent, a “chili pepper stimulation” experiment was conducted on the patient.", + "During the experiment, the patient’s blood pressure before consuming the pepper was 125/83mmHg.", + "The heart rate was 73 beats per minute.", + "After consuming the pepper for 5 minutes, the patient experienced nausea and dizziness.", + "The patient’s heart rate dropped to 37 beats/min.", + "The patient’s blood pressure dropped to 56/37 mmHg.", + "The patient had cold limbs and foggy consciousness.", + "The patient was promptly administered atropine, dopamine, and continuous fluid rehydration.", + "Blood pressure gradually recovered to 150/80mmHg.", + "Heart rate gradually recovered to 90 beats/min.", + "The initial diagnosis was VVS.", + "Despite unsuccessful medical interventions, the patient’s quality of life had been significantly impacted by recurrent syncope episodes.", + "A decision was made to proceed with the ablation of the cardioneuroablation.", + "A cardiac electrophysiological study was performed before surgery.", + "The sinoatrial conduction time, sinus node recovery time, and effective refractory period of the atrioventricular node were all normal for the patient.", + "During ablation, a decrease in heart rate and sinus arrest due to the vagus response caused by radiofrequency energy delivery to the left upper ganglion plexus was observed.", + "Following ventricular pacing protection, there was a notable increase in sinus heart rate subsequent to anatomic ablation at specific locations, including the left superior GP, left inferior GP, right inferior GP, and right anterior GP.", + "Pepper stimulation did not induce arrhythmia after surgery.", + "Head-up tilt testing did not reveal any abnormality.", + "Subsequent to a one-year follow-up, the patient remained asymptomatic." + ], + "summary": "A 60-year-old woman was admitted to the hospital with “repeated loss of consciousness for 20 years.” An electrocardiogram performed revealed sinus rhythm, and echocardiography, head/chest CTs, and a laboratory examination yielded no significant abnormalities. Besides, there were no positive results from the head-up tilt test. The subsequent decrease in heart rate and blood pressure following the ingestion of chili pepper indicated a potential case of vasovagal syncope(VVS) with cardioinhibition. Following cardioneuroablation, there was an observed increase in heart rate compared to pre-procedure levels. Furthermore, no recurrence of similar symptoms was reported during the one-year follow-up period.", + "summary_subclaims": [ + "The patient is a 60-year-old woman.", + "She was admitted to the hospital with 'repeated loss of consciousness for 20 years.'", + "An electrocardiogram performed revealed sinus rhythm.", + "Echocardiography, head/chest CTs, and a laboratory examination yielded no significant abnormalities.", + "There were no positive results from the head-up tilt test.", + "The subsequent decrease in heart rate and blood pressure following the ingestion of chili pepper indicated a potential case of vasovagal syncope(VVS) with cardioinhibition.", + "Following cardioneuroablation, there was an observed increase in heart rate compared to pre-procedure levels.", + "No recurrence of similar symptoms was reported during the one-year follow-up period." + ] + }, + { + "id": "multiclinsum_test_2117_en.txt", + "fulltext": "A 22-year-old Brahmin man presented with complaints of gradual, painless, progressive loss of vision in both eyes for 1 month. It was associated with complaints of headache and dizziness for 1 month. He had a history of multiple painless swellings over his body for the past 1 year. Multiple swellings were present on his face, mandibular area, elbow, arm, and abdomen. His headache was intense on awakening and bending down position. He had a history of fever for 2 days after intake of anti-filariasis medication 1 month back. There was no history of vomiting, unconsciousness, seizures, or change in behavior. He had a history of using tablet amitriptyline 75 mg before sleep for headache for the past 15 days. He was a plumber by occupation. He did not smoke tobacco or drink alcohol; he was not a vegetarian by diet and had a history of eating wild pork meat. There was no significant history of similar illness in his family. There was no significant social and environmental history. On examination he was healthy and well oriented to time, place, and person. His visual acuity was 6/12 in both eyes. Intraocular pressure was 12 mmHg in both eyes. He had multiple small pea-sized nodules which were soft, mobile, non-tender, and well defined; each nodule was approximately 2 × 2 cm. There were no signs of inflammation on his face, mandibular area, elbow, arm, and abdomen .\nHis vital signs and systemic examination were normal. He had no neurological deficit. Pupillary reaction was sluggish in both eyes, otherwise the anterior segment was unremarkable. Posterior segment revealed papilledema in both eyes in the form of blurred, elevated disc margin and tortuous dilated vessels. Parapapillary hemorrhage was present in his left eye. The macula was healthy with good foveal reflex .\nBlood reports were hemoglobin 11.5 gm%, neutrophils (N) 55%, lymphocytes (L) 22%, eosinophils (E) 12%, monocytes (M) 1%, erythrocyte sedimentation rate (ESR) 30 mm/first hour, total leukocyte count (TLC) 7800 cells/mm3, and random blood sugar (RBS) 80 mg%. His serology was negative. His urine routine microscopy was normal. Stool routine microscopy showed absence of parasites. A CT scan showed multiple calcified lesions with scolex in cerebellum and brain parenchyma, with multiple sites of edema on left side of parietal area suggestive of neurocysticercosis .\nA physician consultation was done and he was treated with intravenous injection of dexamethasone and the dose was tapered every 3 days: 4 mg dexamethasone intravenously administered thrice daily for 3 days, 2 mg intravenously administered bi-daily for 3 days, and 2 mg intravenously administered once daily for 3 days. Tablet albendazole 400 mg was prescribed bi-daily for 1 month and tablet valproic acid was prescribed 300 mg bi-daily for 1 month. Unfortunately we lost the follow-up of our patient.", + "fulltext_subclaims": [ + "The patient is a 22-year-old Brahmin man.", + "He presented with complaints of gradual, painless, progressive loss of vision in both eyes for 1 month.", + "He had associated complaints of headache and dizziness for 1 month.", + "He had a history of multiple painless swellings over his body for the past 1 year.", + "Multiple swellings were present on his face, mandibular area, elbow, arm, and abdomen.", + "His headache was intense on awakening and bending down position.", + "He had a history of fever for 2 days after intake of anti-filariasis medication 1 month back.", + "There was no history of vomiting, unconsciousness, seizures, or change in behavior.", + "He had a history of using tablet amitriptyline 75 mg before sleep for headache for the past 15 days.", + "He was a plumber by occupation.", + "He did not smoke tobacco or drink alcohol.", + "He was not a vegetarian by diet and had a history of eating wild pork meat.", + "There was no significant history of similar illness in his family.", + "On examination, he was healthy and well oriented to time, place, and person.", + "Visual acuity was 6/12 in both eyes.", + "Intraocular pressure was 12 mmHg in both eyes.", + "He had multiple small pea-sized nodules which were soft, mobile, non-tender, and well defined.", + "Each nodule was approximately 2 × 2 cm.", + "There were no signs of inflammation on his face, mandibular area, elbow, arm, and abdomen.", + "Vital signs and systemic examination were normal.", + "He had no neurological deficit.", + "Pupillary reaction was sluggish in both eyes.", + "Posterior segment revealed papilledema in both eyes in the form of blurred, elevated disc margin and tortuous dilated vessels.", + "Parapapillary hemorrhage was present in his left eye.", + "The macula was healthy with good foveal reflex.", + "Blood reports showed hemoglobin 11.5 gm%.", + "Neutrophils were 55%.", + "Lymphocytes were 22%.", + "Eosinophils were 12%.", + "Monocytes were 1%.", + "Erythrocyte sedimentation rate was 30 mm/first hour.", + "Total leukocyte count was 7800 cells/mm3.", + "Random blood sugar was 80 mg%.", + "Serology was negative.", + "Urine routine microscopy was normal.", + "Stool routine microscopy showed absence of parasites.", + "A CT scan showed multiple calcified lesions with scolex in cerebellum and brain parenchyma.", + "There were multiple sites of edema on the left side of the parietal area.", + "The CT scan findings were suggestive of neurocysticercosis.", + "He was treated with intravenous injection of dexamethasone.", + "The dexamethasone dose was tapered every 3 days.", + "He received 4 mg dexamethasone intravenously administered thrice daily for 3 days.", + "He received 2 mg dexamethasone intravenously administered bi-daily for 3 days.", + "He received 2 mg dexamethasone intravenously administered once daily for 3 days.", + "Tablet albendazole 400 mg was prescribed bi-daily for 1 month.", + "Tablet valproic acid 300 mg was prescribed bi-daily for 1 month.", + "Unfortunately, we lost the follow-up of our patient." + ], + "summary": "We report a rare case of ocular cysticercosis with multiple disseminated subcutaneous nodules and papilledema in both eyes. A 22-year-old Brahmin man presented with complaints of gradual loss of vision in both eyes and multiple small masses all over his body. On clinical evaluation, multiple subcutaneous nodules were seen on his face, mandibular area, elbow, arm, and abdomen. A fundus evaluation showed bilateral blurred disc margin. The case was managed with steroids and anti-parasitic drugs.", + "summary_subclaims": [ + "We report a rare case of ocular cysticercosis with multiple disseminated subcutaneous nodules and papilledema in both eyes.", + "A 22-year-old Brahmin man presented with complaints of gradual loss of vision in both eyes and multiple small masses all over his body.", + "On clinical evaluation, multiple subcutaneous nodules were seen on his face, mandibular area, elbow, arm, and abdomen.", + "A fundus evaluation showed bilateral blurred disc margin.", + "The case was managed with steroids and anti-parasitic drugs." + ] + }, + { + "id": "multiclinsum_test_2853_en.txt", + "fulltext": "A 48-year-old man, with a history of depression medicated with mirtazapine 30 mg (once daily) and bupropion 300 mg (once daily), who also recently took various herbal products for weight loss, was transferred to the emergency room from a private clinic due to sudden coma. He had been awaiting a diagnostic colonoscopy after taking a bowel preparation containing sodium picosulfate/magnesium oxide/citric acid when he became aggressive and then entered an altered state of consciousness first with shaking and then with no reactivity.\nIn the emergency room as the patient fluctuated between periods of agitation and prostration, orotracheal intubation was performed and he was transferred to an intensive care unit. Blood tests showed severe hyponatremia (110 mmol/l), mild hypokalemia (3.1 mEq/l) and decreased serum osmolality (230 mOsm/kg) .\nThe patient did not have a history of seizures or alcohol consumption. The electrocardiogram was normal, and brain CT and MRI showed no signs of bleeding or acute brain injury. The patient’s neurological symptoms were therefore considered to be related to bowel preparation-induced severe acute hyponatremia. He was treated with a slow intravenous infusion of hypertonic saline (3% NaCl).\nThe patient was extubated within 48 hours following progressive neurological improvement. Complete neurological recovery and normalization of serum sodium levels were achieved on the seventh day of hospitalization .", + "fulltext_subclaims": [ + "The patient is a 48-year-old man.", + "He has a history of depression.", + "He is medicated with mirtazapine 30 mg once daily.", + "He is medicated with bupropion 300 mg once daily.", + "He recently took various herbal products for weight loss.", + "He was transferred to the emergency room from a private clinic due to sudden coma.", + "He had been awaiting a diagnostic colonoscopy.", + "He took a bowel preparation containing sodium picosulfate/magnesium oxide/citric acid.", + "He became aggressive and then entered an altered state of consciousness.", + "In the emergency room, he fluctuated between periods of agitation and prostration.", + "Orotracheal intubation was performed.", + "He was transferred to an intensive care unit.", + "Blood tests showed severe hyponatremia (110 mmol/l).", + "Blood tests showed mild hypokalemia (3.1 mEq/l).", + "Blood tests showed decreased serum osmolality (230 mOsm/kg).", + "The patient did not have a history of seizures.", + "The patient did not have a history of alcohol consumption.", + "The electrocardiogram was normal.", + "Brain CT showed no signs of bleeding or acute brain injury.", + "Brain MRI showed no signs of bleeding or acute brain injury.", + "The patient’s neurological symptoms were considered to be related to bowel preparation-induced severe acute hyponatremia.", + "He was treated with a slow intravenous infusion of hypertonic saline (3% NaCl).", + "The patient was extubated within 48 hours following progressive neurological improvement.", + "Complete neurological recovery was achieved on the seventh day of hospitalization.", + "Normalization of serum sodium levels was achieved on the seventh day of hospitalization." + ], + "summary": "The authors report the case of a 48-year-old man who developed symptomatic hyponatremia (coma) after bowel preparation with sodium picosulfate/magnesium oxide/citric acid prior to a colonoscopy. The patient was admitted to an intensive care unit where other causes of coma were excluded. The symptoms of hyponatremia rapidly resolved after sodium level correction with intravenous administration of hypertonic saline.", + "summary_subclaims": [ + "The authors report the case of a 48-year-old man.", + "The patient developed symptomatic hyponatremia (coma) after bowel preparation with sodium picosulfate/magnesium oxide/citric acid prior to a colonoscopy.", + "The patient was admitted to an intensive care unit.", + "Other causes of coma were excluded.", + "The symptoms of hyponatremia rapidly resolved after sodium level correction.", + "The sodium level correction was achieved with intravenous administration of hypertonic saline." + ] + }, + { + "id": "multiclinsum_test_70_en.txt", + "fulltext": "A 29-year-old male complaining of bilateral forearm tingling and bilateral upper extremity weakness visited the outpatient clinic of our department.\nHis primary symptoms were bilateral forearm tingling and pain. These symptoms began 6 mo prior to the visit. Within a few days, bilateral upper extremity weakness also began. There was no improvement in symptoms for several weeks. Thus, he visited the neurology department of another hospital. Under suspicion of radiculopathy, cervical spine magnetic resonance imaging (MRI) with enhancement and electrodiagnostic study were performed. However, abnormalities were not found. During the follow-up period at that hospital, brain MRI, computed tomography, and arteriography of the left upper extremity were performed, but a diagnosis could not be made.\nLater, when the patient visited the hospital, he complained of bilateral forearm tingling, weakness, and bilateral arm muscle spasms.\nThe patient was not taking any medications and had no previous diagnoses. The patient did not have any history of hospitalization or surgery.\nHe had no familial history of congenital, allergic, or systemic disease. The patient smoked approximately half a pack of cigarettes a day for 5 years and did not drink alcohol.\nOn physical examination, no external wound was observed. The circumference of both arms was not different and distinct atrophy of biceps or deltoid muscles was not present. The range of motion for both shoulders and elbow joints was not limited. The pain was not aggravated by movement.\nParesthesia was present in both forearms, but the symptom site did not match with peripheral nerve distribution or cervical root dermatome. Manual muscle testing was grade 5 throughout the right and left upper extremities except in bilateral elbow and shoulder flexion. Manual muscle test of bilateral elbow and shoulder flexion showed grade 4. The patient could flex both his elbows with a 2 kg dumbbell but not with a 5 kg. The deep tendon reflex of both bicep muscles was symmetrically decreased.\nBefore the symptoms began, he started working out at a fitness center. He did weight training, which is commonly practiced. However, he extensively stretched his pectoralis minor muscles. Figure shows the stretching exercise of the pectoralis minor that the patient described. Both shoulder joints were mildly extended, 90° externally rotated, and 45° abducted. Both scapulae were retracted, and the elbow joints were bent approximately 90°. The patient placed his elbows on the wall right next to the door and pushed his trunk forward.\nThere were no abnormalities in laboratory tests including complete blood count, electro profile, liver function test, kidney function test, routine urine analysis, blood coagulation test, and thyroid function test. Acetylcholine receptor antibody, erythrocyte sedimentation rate, C-reactive protein, vitamin B12, and folate were within normal limits. In addition, blood calcium, ionized calcium, creatine kinase, and phosphate were within normal limits.\nTables and show the electrodiagnostic study of the patient. Bilateral axillary, musculocutaneous, median, and ulnar compound motor action potential (CMAP) were within normal limits. Bilateral median, ulnar, and bilateral lateral antebrachial cutaneous SNAP were within normal limits. Bilateral median F-waves were within normal limits. Electromyography of the bilateral upper extremities showed abnormal spontaneous activities in the bilateral biceps and brachialis muscles with reduced recruitment and interference pattern. These electrophysiologic findings were indicative of bilateral musculocutaneous neuropathy.\nTables and show the patient’s electrodiagnostic study performed at a previous hospital approximately 4 mo before the follow-up study. Compared with Table , Table shows that amplitude of each musculocutaneous CMAP was decreased.\nAs mentioned above, electrophysiologic findings were indicative of bilateral musculocutaneous neuropathy. To confirm the diagnosis, MRI of both arms was performed.\nFigures and showed the MRI of both arms and brachial plexus of the patient. Significant abnormality was not observed in either brachial plexus and distal peripheral nerves.\nFigure showed the patient’s cervical spine MRI performed at a previous hospital approximately 6 mo before the visit to our clinic. Specific abnormalities were not observed on cervical spine MRI.", + "fulltext_subclaims": [ + "A 29-year-old male complaining of bilateral forearm tingling and bilateral upper extremity weakness visited the outpatient clinic.", + "His primary symptoms were bilateral forearm tingling and pain.", + "These symptoms began 6 mo prior to the visit.", + "Bilateral upper extremity weakness began within a few days.", + "There was no improvement in symptoms for several weeks.", + "He visited the neurology department of another hospital.", + "Under suspicion of radiculopathy, cervical spine MRI with enhancement and electrodiagnostic study were performed.", + "Abnormalities were not found.", + "During the follow-up period at that hospital, brain MRI, computed tomography, and arteriography of the left upper extremity were performed.", + "A diagnosis could not be made.", + "Later, when the patient visited the hospital, he complained of bilateral forearm tingling, weakness, and bilateral arm muscle spasms.", + "The patient was not taking any medications.", + "The patient had no previous diagnoses.", + "The patient did not have any history of hospitalization or surgery.", + "He had no familial history of congenital, allergic, or systemic disease.", + "The patient smoked approximately half a pack of cigarettes a day for 5 years.", + "On physical examination, no external wound was observed.", + "The circumference of both arms was not different.", + "Distinct atrophy of biceps or deltoid muscles was not present.", + "The range of motion for both shoulders and elbow joints was not limited.", + "The pain was not aggravated by movement.", + "Paresthesia was present in both forearms.", + "The symptom site did not match with peripheral nerve distribution or cervical root dermatome.", + "Manual muscle testing was grade 5 throughout the right and left upper extremities except in bilateral elbow and shoulder flexion.", + "Manual muscle test of bilateral elbow and shoulder flexion showed grade 4.", + "The patient could flex both his elbows with a 2 kg dumbbell but not with a 5 kg.", + "The deep tendon reflex of both bicep muscles was symmetrically decreased.", + "Before the symptoms began, he started working out at a fitness center.", + "He did weight training, which is commonly practiced.", + "He extensively stretched his pectoralis minor muscles.", + "Both shoulder joints were mildly extended, 90° externally rotated, and 45° abducted.", + "Both scapulae were retracted.", + "The elbow joints were bent approximately 90°.", + "The patient placed his elbows on the wall right next to the door and pushed his trunk forward.", + "There were no abnormalities in laboratory tests including complete blood count, electro profile, liver function test, kidney function test, routine urine analysis, blood coagulation test, and thyroid function test.", + "Acetylcholine receptor antibody, erythrocyte sedimentation rate, C-reactive protein, vitamin B12, and folate were within normal limits.", + "Blood calcium, ionized calcium, creatine kinase, and phosphate were within normal limits.", + "Bilateral axillary, musculocutaneous, median, and ulnar CMAP were within normal limits.", + "Bilateral median, ulnar, and bilateral lateral antebrachial cutaneous SNAP were within normal limits.", + "Bilateral median F-waves were within normal limits.", + "Electromyography of the bilateral upper extremities showed abnormal spontaneous activities in the bilateral biceps and brachialis muscles with reduced recruitment and interference pattern.", + "These electrophysiologic findings were indicative of bilateral musculocutaneous neuropathy.", + "MRI of both arms was performed.", + "Significant abnormality was not observed in either brachial plexus and distal peripheral nerves.", + "Specific abnormalities were not observed on cervical spine MRI." + ], + "summary": "A 29-year-old male complaining of bilateral forearm tingling and upper extremity weakness visited the outpatient clinic. The symptoms began 6 mo prior, and he visited another hospital before visiting our department. The diagnosis was not made even after cervical spine magnetic resonance imaging, electrodiagnostic study, brain magnetic resonance imaging, and arteriography were conducted. The patient performed unique exercises that stretched the pectoralis minor and coracobrachialis muscles. On the follow-up electrodiagnostic study, abnormal spontaneous activities in the bilateral biceps and brachialis muscles were observed. The patient was diagnosed with bilateral musculocutaneous neuropathy. Steroid pulse therapy was administered for approximately 6 wk. After treatment, his muscle strength returned to the predisease condition.", + "summary_subclaims": [ + "A 29-year-old male complaining of bilateral forearm tingling and upper extremity weakness visited the outpatient clinic.", + "The symptoms began 6 mo prior.", + "The diagnosis was not made even after cervical spine magnetic resonance imaging, electrodiagnostic study, brain magnetic resonance imaging, and arteriography were conducted.", + "The patient performed unique exercises that stretched the pectoralis minor and coracobrachialis muscles.", + "On the follow-up electrodiagnostic study, abnormal spontaneous activities in the bilateral biceps and brachialis muscles were observed.", + "The patient was diagnosed with bilateral musculocutaneous neuropathy.", + "Steroid pulse therapy was administered for approximately 6 wk.", + "After treatment, his muscle strength returned to the predisease condition." + ] + }, + { + "id": "multiclinsum_test_138_en.txt", + "fulltext": "A previously healthy 45-year-old woman had an cesarean section delivery. She underwent total abdominal hysterectomy, bilateral salpingectomy and adhesiolysis 3 days after admission because conservative treatment of adenomyosis was ineffective. The patient had a positive cephalosporin skin test and was given clindamycin to prevent postoperative infection. However, she developed a sudden onset chills, a high fever (39.0 °C), and a fast heart rate (115 bpm) but had normal blood pressure (118/69 mmHg) 14 h after the surgery. Laboratory blood samples obtained when the patient was febrile showed that the patient’s white blood cell (WBC) count was 8.0 × 10^9/l with 94.4% neutrophils, and the serum C-reactive protein (CRP) level was 7.0 mg/l. Levofloxacin was added to expand the antibacterial spectrum. However, these symptoms did not improve, and she subsequently developed nausea, vomiting, abdominal distension, abdominal pain, diarrhea and oliguria. At that time, the serum laboratory tests showed that the WBC count (1.9 × 10^9/l) fell below the normal range, and CRP (152 mg/l) was further elevated. Twenty-four hours later, the patient showed anuria. Physical examination detected tachycardia (152 bpm) and hypotension (72/39 mmHg). The patient’s hemodynamic parameters, fever chart and antibiotics administered are shown in Fig. .\nThe patient was rapidly admitted to the intensive care unit (ICU). Arterial blood gas indicated high anion gap metabolic acidosis with respiratory alkalosis with a pH of 7.33, anion gap of 16.8 and lactic acid of 4.4. Her laboratory tests showed low albumin (22.3 g/l), high serum creatinine (251.9 μmol/l), dysfunction of coagulation (INR1.97, PT22.4 s), and markedly elevated D-dimer (13.477 mg/l). Computed tomography (CT) of the abdomen and pelvis was performed to rule out the presence of a possible occult abscess . She was instantly placed empirically on imipenem/cilastatin and linezolid, given fluid resuscitation and started on noradrenaline via a peripheral intravenous catheter. Afterwards, she received intravenous infusion of albumin (80 g) and virus inactivated plasma (300 ml). Three days after surgery, two sets of blood cultures were positive for S. mitis in the aerobic and anaerobic bottles with a time to positivity of less than 72 h. Antimicrobial susceptibility testing revealed resistance towards clindamycin, moderate resistance towards erythromycin and sensitivity towards penicillin, levofloxacin, vancomycin and linezolid. Henceforward, the patient was diagnosed with STSS caused by S. mitis. Frequent replacement of antibiotics may lead to the emergence of antibiotic-resistant bacteria, so we did not use penicillin immediately.\nOn day 4 after surgery, the patient developed moderate acute respiratory distress syndrome (ARDS) with a PaO2/FiO2 ratio of 162.5 mmHg. Pulmonary edema and bilateral pleural effusions were observed on chest radiographs. It was necessary to intubate and ventilate the patient. As the PaO2/FiO2 ratio increased to 377 mmHg and pulmonary edema and pleural effusions were improved on day 8 after surgery, ventilation could be stopped.\nDue to new-onset thrombocytopenia (48 × 10^9/l) thought to be associated with STSS and continued fever despite receiving adequate antibiotic therapy, linezolid was discontinued, and imipenem/cilastatin, vancomycin and penicillin were administered on day 5 after surgery. Two days later, her temperature dropped to the normal range. Additionally, there was no evidence of gram-negative bacilli infection, so we replaced imipenem/cilastatin with levofloxacin based on antimicrobial susceptibility testing. However, her temperature rose again 1 day later . Soon afterwards, her temperature fluctuated between low and medium heat. On day 13 after surgical intervention, physical examination showed that she developed skin redness and subcutaneous induration on the upper left side of the incision. We considered it to be cellulitis of the incision according to ultrasound imaging and the clinical manifestation, for which she underwent debridement. In addition, we used piperacillin/tazobactam instead of penicillin and levofloxacin. The hemolytic streptococcal spread of infection to the incision cannot be excluded, although the local secretion smear and cultures were sterile. Her temperature gradually dropped, and her blood pressure and lactic acidosis recovered to the normal range; hence, she was transferred to the general ward on the 15th postoperative day.\nOne day later, her temperature suddenly rose to 38.8 °C again despite adequate drainage of the incision . We considered that the reason for the fever was still related to cellulitis of the incision. Therefore, linezolid was used in place of vancomycin to increase the drug concentration in the skin and soft tissues. Her temperature no longer rose to 38 °C 18 days after surgery . The antibiotics were stopped on the 27th day after surgery. In summary, the patient was treated with antibiotics for a total of 4 weeks. She was discharged when her vital signs were stable, and the incision healed on day 40 after surgery.", + "fulltext_subclaims": [ + "The patient was a previously healthy 45-year-old woman.", + "She had a cesarean section delivery.", + "She underwent total abdominal hysterectomy, bilateral salpingectomy, and adhesiolysis.", + "The procedure was performed 3 days after admission.", + "The procedure was done because conservative treatment of adenomyosis was ineffective.", + "The patient had a positive cephalosporin skin test.", + "She was given clindamycin to prevent postoperative infection.", + "She developed a sudden onset of chills.", + "She developed a high fever of 39.0 °C.", + "She had a fast heart rate of 115 bpm.", + "She had normal blood pressure of 118/69 mmHg.", + "The symptoms occurred 14 hours after the surgery.", + "The WBC count was 8.0 × 10^9/l.", + "The neutrophil percentage was 94.4%.", + "The serum CRP level was 7.0 mg/l.", + "Levofloxacin was added to expand the antibacterial spectrum.", + "The symptoms did not improve.", + "She developed nausea.", + "She developed vomiting.", + "She developed abdominal distension.", + "She developed abdominal pain.", + "She developed diarrhea.", + "She developed oliguria.", + "The WBC count fell below the normal range.", + "The CRP was further elevated.", + "The patient showed anuria.", + "The patient had tachycardia of 152 bpm.", + "The patient had hypotension of 72/39 mmHg.", + "Arterial blood gas showed high anion gap metabolic acidosis with respiratory alkalosis.", + "The pH was 7.33.", + "The anion gap was 16.8.", + "The lactic acid was 4.4.", + "The albumin was 22.3 g/l.", + "The serum creatinine was 251.9 μmol/l.", + "The INR was 1.97.", + "The PT was 22.4 s.", + "The D-dimer was 13.477 mg/l.", + "Computed tomography of the abdomen and pelvis was performed.", + "The patient was placed on imipenem/cilastatin and linezolid.", + "She received fluid resuscitation.", + "She received noradrenaline via a peripheral intravenous catheter.", + "She received intravenous infusion of albumin (80 g).", + "She received virus inactivated plasma (300 ml).", + "Two sets of blood cultures were positive for S. mitis.", + "The time to positivity was less than 72 h.", + "Antimicrobial susceptibility testing revealed resistance towards clindamycin.", + "Antimicrobial susceptibility testing revealed moderate resistance towards erythromycin.", + "Antimicrobial susceptibility testing revealed sensitivity towards penicillin.", + "Antimicrobial susceptibility testing revealed sensitivity towards levofloxacin.", + "Antimicrobial susceptibility testing revealed sensitivity towards vancomycin.", + "Antimicrobial susceptibility testing revealed sensitivity towards linezolid.", + "The patient was diagnosed with STSS caused by S. mitis.", + "The patient developed moderate ARDS with a PaO2/FiO2 ratio of 162.5 mmHg.", + "Pulmonary edema and bilateral pleural effusions were observed.", + "The patient was intubated and ventilated.", + "The PaO2/FiO2 ratio increased to 377 mmHg.", + "Pulmonary edema and pleural effusions improved.", + "Ventilation could be stopped.", + "The patient developed thrombocytopenia of 48 × 10^9/l.", + "The thrombocytopenia was thought to be associated with STSS.", + "Linezolid was discontinued.", + "Imipenem/cilastatin, vancomycin, and penicillin were administered.", + "The temperature dropped to the normal range.", + "There was no evidence of gram-negative bacilli infection.", + "Imipenem/cilastatin was replaced with levofloxacin.", + "The temperature rose again 1 day later.", + "The temperature fluctuated between low and medium heat.", + "The patient developed skin redness on the upper left side of the incision.", + "The patient developed subcutaneous induration on the upper left side of the incision.", + "The incision was considered to be cellulitis.", + "The patient underwent debridement.", + "Piperacillin/tazobactam was used instead of penicillin and levofloxacin.", + "The hemolytic streptococcal spread of infection to the incision cannot be excluded.", + "The local secretion smear and cultures were sterile.", + "The temperature gradually dropped.", + "The blood pressure recovered to the normal range.", + "The lactic acidosis recovered to the normal range.", + "The patient was transferred to the general ward.", + "The patient's temperature suddenly rose to 38.8 °C.", + "The fever was considered to be related to cellulitis of the incision.", + "Linezolid was used in place of vancomycin.", + "The temperature no longer rose to 38 °C.", + "The antibiotics were stopped on the 27th day after surgery.", + "The patient was discharged when her vital signs were stable.", + "The incision healed on day 40 after surgery." + ], + "summary": "We report a case of STSS caused by S. mitis in a healthy 45-year-old woman. She presented with fever 14 h after surgery and with hypotension 24 h later, and she subsequently suffered from septic shock, low albumin, dysfunction of coagulation, acute kidney dysfunction, respiratory alkalosis and metabolic acidosis, acute respiratory distress syndrome and cellulitis of the incision. The diagnosis was obtained through clinical manifestation and blood culture examination. The patient was treated with aggressive fluid resuscitation, adequate antibiotics for a total of 4 weeks, respiratory support, and surgical debridement and drainage of the incision. She was discharged after her vital signs returned to normal and the incision healed on day 40 after surgery.", + "summary_subclaims": [ + "The patient was a 45-year-old woman.", + "The patient was healthy.", + "The case involved STSS caused by S. mitis.", + "The patient presented with fever 14 h after surgery.", + "The patient had hypotension 24 h after surgery.", + "The patient subsequently suffered from septic shock.", + "The patient had low albumin.", + "The patient had dysfunction of coagulation.", + "The patient had acute kidney dysfunction.", + "The patient had respiratory alkalosis.", + "The patient had metabolic acidosis.", + "The patient had acute respiratory distress syndrome.", + "The patient had cellulitis of the incision.", + "The diagnosis was obtained through clinical manifestation.", + "The diagnosis was obtained through blood culture examination.", + "The patient was treated with aggressive fluid resuscitation.", + "The patient received adequate antibiotics for a total of 4 weeks.", + "The patient received respiratory support.", + "The patient had surgical debridement and drainage of the incision.", + "The patient was discharged after her vital signs returned to normal.", + "The patient was discharged after the incision healed.", + "The patient was discharged on day 40 after surgery." + ] + }, + { + "id": "multiclinsum_test_3029_en.txt", + "fulltext": "Patient: Female, 61-year-old\n\nFinal Diagnosis: Dilated cardiomyopathy\n\nSymptoms: Dyspnea on exertion\n\nMedication:—\n\nClinical Procedure: Medications and CRT\n\nA 61-year-old woman with no medical history was admitted to our hospital in September 2008 for 2 months of progressive dyspnea. She was documented to have decompensated HF with New York Heart Association (NYHA) II functional limitations. She had no history of tobacco smoking, alcohol consumption, or substance abuse. Results of the physical examination were: height, 150 cm; weight, 42 kg; body mass index (BMI), 18.7 kg/m2; blood pressure, 120/66 mmHg; heart rate, 73 beats/min; and oxygen saturation, 94% (room air). Her dyspnea on exertion was class II based on the NYHA classification. On auscultation, a third heart sound (S3) and an apical systolic murmur were detected.\n\nChest radiography revealed cardiomegaly and bilateral pleural effusions. ECG showed a sinus rhythm with LBBB and a QRS complex duration of 140 ms. Echocardiography revealed severe LV enlargement with impaired systolic function and an LVEF of 18% (normal range, 55–65%). LV diastolic to systolic dimension (LVDd/LVDs) was 56/48 mm (normal range, 40–55/30–45 mm), and moderate MR was observed. Based on these findings, the patient was admitted with a diagnosis of HF.\n\nSecondary cardiomyopathy associated with autoimmune disease, metabolic disease, and inflammatory disease may show echocardiographic findings similar to DCM. Blood tests results were normal and ruled out these diseases. Coronary angiography was also performed to exclude ischemic cardiomyopathy, and it did not demonstrate significant coronary artery disease. Cardiac magnetic resonance imaging demonstrated LV dilation with an LVEF of 16% and no evidence of abnormal gadolinium enhancement. Thus, no findings were suggestive of secondary cardiomyopathy after these examinations. Along with these results, and based on the 2006 American Heart Association Classification of “Contemporary definitions and classification of the cardiomyopathies,” we reached a final diagnosis of DCM.\n\nDiuretic treatment was initiated (furosemide: 40 mg/day, initially administered via intravenous injection and then orally) in combination with an angiotensin II receptor blocker (candesartan: 4 mg/day) and a β-blocker (carvedilol) for secondary prevention of HF. As the prognostic improvement associated with β-blockers is dose-dependent, the guidelines recommended increasing the dosage in accordance with the tolerance level of the patient. In our case, the carvedilol dosage was increased to 10 mg/day. The use of mineralocorticoid/aldosterone receptor antagonists and a further increase in the carvedilol dosage were not possible because of hypotension. The patient’s HF improved, and she was subsequently discharged.\n\nIn October 2009, the patient was readmitted because of HF re-exacerbation, despite ongoing pharmaceutical treatment. Echocardiography revealed an LVEF of 30% and an LVDd/LVDs of 67/54 mm, and ECG indicated a QRS width of 144 ms. We determined that CRT was required; however, the patient refused because of fear of surgery. Hence, pharmaceutical treatment alone was continued. In June 2011, the patient’s HF worsened, and she was readmitted with significant widening of the QRS complex (160 ms), decreased LVEF (27%), and rapidly increased LVDd/LVDs (79/69 mm). In July 2011, she consented to CRT, and a pacemaker (AllureTM, St Jude Medical, MN, USA) was implanted. The placement of the LV leads resulted in a high LV pacing threshold; however, no other positions were feasible because there was no other coronary vein branch wherein the LV lead could be inserted with a good threshold. Immediately after implantation, the LVEF increased and QRS width decreased.\n\nEchocardiography performed in August 2011 revealed significant improvements in both the LVEF (46%) and LV enlargement (LVDd/Ds of 56/43 mm), the QRS width was 124 ms, and we were able to increase the carvedilol dosage to 20 mg/day. Follow-up echocardiography performed in June 2012 confirmed the improvement in the LVEF (65%) and LVDd/LVDs (47/30 mm), revealed QRS width of 136 ms, and showed mild MR.\n\nAt this point, due to the high threshold of the LV pacing lead, the remaining battery power was estimated to last less than 1 year; thus, we decided to discontinue biventricular pacing. Although the LBBB persisted, follow-up ECG and echocardiography indicated that the QRS width had not increased (136 ms) and there was no deterioration in MR or LVEF. Therefore, with the patient’s consent, CRT was discontinued in October 2012 to preserve the battery. We changed the mode from DDD to AAI as there was a mild bradycardia, possibly due to the increased β-blocker dose. It was clearly communicated to the patient that CRT would be promptly restarted if there was any sign of HF re-exacerbation; she was carefully monitored for the following 4 years, during which there was no deterioration of cardiac function. Echocardiography and ECG revealed an LVEF of 69%, LVDd/LVDs of 44/27 mm, and a QRS width of 130 ms during follow-up in August 2014, and an LVEF of 60%, LVDd/LVDs of 42/30 mm, and a QRS width of 126 ms in June 2016. The latest follow-up in November 2018 revealed an LVEF of 64%, LVDd/LVDs of 44/30 mm, and a QRS width of 132 ms.\n\nIn anticipation of probable cardiac remodeling that could re-exacerbate the HF, and thus require prompt resumption of CRT, a generator exchange surgery was performed in June 2016. At the most recent follow-up in 2020, CRT had not been resumed and the patient’s status remained stable without signs of re-exacerbation.", + "fulltext_subclaims": [ + "The patient is a 61-year-old woman.", + "She was admitted in September 2008 for 2 months of progressive dyspnea.", + "She had decompensated HF with NYHA II functional limitations.", + "She had no history of tobacco smoking, alcohol consumption, or substance abuse.", + "Her BMI was 18.7 kg/m2.", + "Her oxygen saturation was 94% on room air.", + "Her dyspnea on exertion was class II based on the NYHA classification.", + "On auscultation, a third heart sound (S3) and an apical systolic murmur were detected.", + "Chest radiography revealed cardiomegaly and bilateral pleural effusions.", + "ECG showed a sinus rhythm with LBBB and a QRS complex duration of 140 ms.", + "Echocardiography revealed an LVEF of 18%.", + "LV diastolic to systolic dimension was 56/48 mm.", + "Moderate MR was observed.", + "The patient was admitted with a diagnosis of HF.", + "Blood tests ruled out secondary cardiomyopathy associated with autoimmune, metabolic, or inflammatory disease.", + "Coronary angiography did not demonstrate significant coronary artery disease.", + "Cardiac magnetic resonance imaging demonstrated an LVEF of 16%.", + "There was no evidence of abnormal gadolinium enhancement.", + "The final diagnosis was dilated cardiomyopathy.", + "Diuretic treatment with furosemide was initiated.", + "Candesartan 4 mg/day was started.", + "Carvedilol was started for secondary prevention of HF.", + "The carvedilol dosage was increased to 10 mg/day.", + "The use of mineralocorticoid/aldosterone receptor antagonists was not possible due to hypotension.", + "The patient was discharged after improvement.", + "In October 2009, the patient was readmitted due to HF re-exacerbation.", + "Echocardiography revealed an LVEF of 30%.", + "ECG indicated a QRS width of 144 ms.", + "CRT was determined to be required.", + "The patient refused CRT due to fear of surgery.", + "In June 2011, the patient was readmitted with worsening HF.", + "Echocardiography showed an LVEF of 27%.", + "The QRS complex was 160 ms.", + "LV leads resulted in a high LV pacing threshold.", + "No other coronary vein branch was feasible for LV lead insertion.", + "Immediately after CRT implantation, the LVEF increased.", + "The QRS width decreased immediately after CRT implantation.", + "Echocardiography in August 2011 showed an LVEF of 46%.", + "The carvedilol dosage was increased to 20 mg/day.", + "Follow-up echocardiography in June 2012 showed an LVEF of 65%.", + "The remaining battery power was estimated to last less than 1 year.", + "CRT was discontinued in October 2012.", + "The mode was changed from DDD to AAI.", + "CRT was not resumed during the following 4 years.", + "Echocardiography in August 2014 showed an LVEF of 69%.", + "Echocardiography in June 2016 showed an LVEF of 60%.", + "The latest follow-up in November 2018 showed an LVEF of 64%.", + "A generator exchange surgery was performed in June 2016.", + "CRT had not been resumed at the most recent follow-up in 2020." + ], + "summary": "A 61-year-old woman with a nonischemic cardiomyopathy was admitted to our hospital in September 2008 for the treatment of heart failure (HF). Cardiac assessment revealed impaired LV function with an ejection fraction of 18%, LV dilatation, and left bundle branch block (LBBB). Despite optimized medical treatment, her HF progressed, with a rapid increase in LV chamber size, mitral regurgitation, and widening of the QRS complex. In July 2011, the patient initially refused CRT, but later consented to the procedure; CRT pacemaker implantation was subsequently performed. Thereafter, the LVEF improved from 27% to 46%, LV diastolic dimension decreased rapidly from 79 mm to 56 mm, and LVEF (65%) and LV size (47 mm) normalized within 1 year later. As of August 2012, battery exchange was needed within 1 year because of high LV pacing thresholds. In October 2012, although CRT discontinuation was not recommended, we discontinued CRT to conserve battery life with the patient’s consent, hoping to maintain her condition with pharmaceutical treatment. She remained stable through January 2020, with no indication of re-exacerbation.", + "summary_subclaims": [ + "The patient was a 61-year-old woman with a nonischemic cardiomyopathy.", + "She was admitted to the hospital in September 2008 for treatment of heart failure.", + "Cardiac assessment revealed an ejection fraction of 18%.", + "LV dilatation was present.", + "Left bundle branch block was present.", + "Despite optimized medical treatment, heart failure progressed.", + "LV chamber size increased rapidly.", + "Mitral regurgitation was present.", + "The QRS complex widened.", + "In July 2011, the patient initially refused CRT.", + "CRT pacemaker implantation was performed.", + "LVEF improved from 27% to 46%.", + "LV diastolic dimension decreased from 79 mm to 56 mm.", + "LVEF normalized to 65% within 1 year.", + "LV size normalized to 47 mm within 1 year.", + "Battery exchange was needed within 1 year because of high LV pacing thresholds.", + "CRT discontinuation was not recommended.", + "CRT was discontinued to conserve battery life with the patient’s consent.", + "She remained stable through January 2020.", + "There was no indication of re-exacerbation." + ] + }, + { + "id": "multiclinsum_test_2425_en.txt", + "fulltext": "A 60-year-old Chinese male farmer presented with a 3-mo history of right scrotal enlargement.\nThe patient presented with right scrotal enlargement and had no scrotal tenderness, chills, fever, or other discomfort. No abnormality of the left testis, epididymis, or spermatic cord was discerned. The patient did not self-medicate or seek alternative therapies. He reported no lumbar or abdominal pain and no increased frequency, urgency, or pain associated with urination, but had a slight weight loss.\nThe patient had no history of trauma, tuberculosis, or other relevant infectious disease.\nThe patient denied any family history.\nA 4 cm × 5 cm, slightly moveable, solid mass was palpated in the right scrotum, which drooped and was pale in color. No normal testicular or epididymal structures were palpated in the affected testis. No abnormality of the left testis, epididymis, or spermatic cord was discerned.\nThe results such as routine hematological testing, blood sedimentation rate, vascular endothelial growth factor, human chorionic gonadotropin (HCG), serum carbohydrate antigen (CA)199, CA125, CA153, alpha-fetoprotein (AFP), thymidine kinase 1, and carcinoembryonic antigen (CEA) were normal.\nWithin 1 wk from presentation, the patient underwent scrotal ultrasound showing a 4.5 cm × 2.7 cm × 3.7 cm oval-shaped hypoechoic mass, with uneven internal echogenicity in the right testicle . Color Doppler showed scattered color blood flow signals within the lesion. Meanwhile, the patient underwent computed tomography (CT), which revealed an enlarged right testis, with indistinct contour, uneven density, and uniform nodular change . No normal testicular or epididymal structures were palpated in the affected testis.", + "fulltext_subclaims": [ + "The patient is a 60-year-old Chinese male farmer.", + "The patient had a 3-mo history of right scrotal enlargement.", + "The patient had no scrotal tenderness.", + "The patient had no fever.", + "The patient did not self-medicate.", + "The patient had no history of trauma.", + "The patient denied any family history.", + "A 4 cm × 5 cm, slightly moveable, solid mass was palpated in the right scrotum.", + "No normal testicular or epididymal structures were palpated in the affected testis.", + "The results of routine hematological testing were normal.", + "The results of blood sedimentation rate were normal.", + "The results of vascular endothelial growth factor were normal.", + "The results of human chorionic gonadotropin (HCG) were normal.", + "The results of alpha-fetoprotein (AFP) were normal.", + "The results of carcinoembryonic antigen (CEA) were normal.", + "The patient underwent scrotal ultrasound within 1 wk from presentation.", + "The ultrasound showed a 4.5 cm × 2.7 cm × 3.7 cm oval-shaped hypoechoic mass in the right testicle.", + "Color Doppler showed scattered color blood flow signals within the lesion.", + "The patient underwent computed tomography (CT) within 1 wk from presentation.", + "CT revealed an enlarged right testis with indistinct contour.", + "CT showed uneven density in the right testis." + ], + "summary": "A 60-year-old Chinese man presented with a solid mass in the right scrotum. The mass was surgically removed and spermatocytic tumor was diagnosed. On microscopy, the tumor cells displayed an unusual arrangement in lobules, presenting a pseudo-glandular appearance. To summarize and compare the diagnostic features of this tumor and those of the differential diagnoses, we report our case findings and those mentioned in the literature for various testicular tumors. Although imaging methods can detect masses early in development, their diagnostic capabilities are limited. Biopsy, histopathology, and immunohistochemistry are necessary for confirmatory diagnosis.", + "summary_subclaims": [ + "A 60-year-old Chinese man presented with a solid mass in the right scrotum.", + "The mass was surgically removed and spermatocytic tumor was diagnosed.", + "On microscopy, the tumor cells displayed an unusual arrangement in lobules.", + "The tumor cells presented a pseudo-glandular appearance.", + "We report our case findings and those mentioned in the literature for various testicular tumors.", + "Imaging methods can detect masses early in development.", + "Biopsy, histopathology, and immunohistochemistry are necessary for confirmatory diagnosis." + ] + }, + { + "id": "multiclinsum_test_2687_en.txt", + "fulltext": "A 56-year-old man with no history of tobacco use or alcohol consumption presented with a three-month history of an enlarging left-sided neck mass and worsening headaches. A positron emission tomography/computed tomography (PET/CT) showed an [18 F]fluorodeoxyglucose FDG-avid soft tissue density at the left tongue base measuring approximately 1.8 × 2 cm, a centrally hypodense hypermetabolic left level IIB nodal conglomerate measuring 3.6 × 4 cm, and multiple bilateral hypermetabolic cervical lymph nodes, without evidence of distant metastasis. Brain MRI was negative for brain metastasis.\nThe patient underwent a core biopsy of the left neck level II node which read as a poorly differentiated neuroendocrine carcinoma consistent with small cell carcinoma.\nCore biopsy of the left neck level II node revealed sheets of malignant cells with small to intermediate-sized nuclei, indistinct nucleoli, and scant cytoplasm consistent with SCC. The tumor exhibited areas of necrosis as well as abundant mitotic figures and apoptotic bodies. The neoplastic cells were positive for cytokeratin AE1/AE3, synaptophysin, p16, and TTF-1 with a nuclear staining pattern; they were negative for cytokeratin 5/6, CAM 5.2, p63, chromogranin, CD56, and EBV (by in-situ hybridization) .\nThe tumor was positive for p16, but the combined morphologic and immunophenotypic features argued against conventional HPV-associated OPSqCC. Polymerase chain reaction demonstrated that the tumor was positive for HPV16, negative for HPV18, 31, 33, 35, 39, 45, 51, 52, 56, 59, 66, and 68.\nThe tumor was staged T1N2cM0 (stage IVA). A percutaneous endoscopic gastrostomy tube (PEG) was placed before the beginning of treatment to meet his nutritional and hydration needs during treatment. He received four cycles of chemotherapy at 21 day-intervals. The chemotherapy regimen consisted of cisplatin 75 mg/m2 on day one and etoposide 80 mg/m2 on days one to three. On cycle two, day eight, he started radiotherapy to the oropharynx and involved neck nodes. He received a dose of 70 Gray (2 Gy/fraction) over a seven week-period. During the concomitant phase of chemo-radiation, the patient experienced grade IV mucositis, grade II nausea, and dehydration for which he received additional outpatient fluid and electrolyte replacement. Due to grade III neutropenia, the dose of cisplatin and etoposide was reduced by 25% during the last cycle of chemotherapy.\nThree months after completion of therapy, a PET/CT showed complete resolution of the tumor and metastatic lymph nodes along with and no evidence of distant metastasis . He also had complete resolution of his mucositis and was able to resume a full oral diet resulting in removal of the PEG tube.", + "fulltext_subclaims": [ + "The patient is a 56-year-old man.", + "The patient has no history of tobacco use.", + "The patient has no history of alcohol consumption.", + "The patient had a three-month history of an enlarging left-sided neck mass.", + "The patient had worsening headaches.", + "A PET/CT showed an [18 F]fluorodeoxyglucose FDG-avid soft tissue density at the left tongue base.", + "The FDG-avid soft tissue density at the left tongue base measured approximately 1.8 × 2 cm.", + "A PET/CT showed a centrally hypodense hypermetabolic left level IIB nodal conglomerate.", + "The left level IIB nodal conglomerate measured 3.6 × 4 cm.", + "A PET/CT showed multiple bilateral hypermetabolic cervical lymph nodes.", + "There was no evidence of distant metastasis on the PET/CT.", + "Brain MRI was negative for brain metastasis.", + "The patient underwent a core biopsy of the left neck level II node.", + "The core biopsy of the left neck level II node read as a poorly differentiated neuroendocrine carcinoma.", + "The core biopsy of the left neck level II node was consistent with small cell carcinoma.", + "The tumor exhibited areas of necrosis.", + "The tumor exhibited abundant mitotic figures.", + "The tumor exhibited apoptotic bodies.", + "The neoplastic cells were positive for cytokeratin AE1/AE3.", + "The neoplastic cells were positive for synaptophysin.", + "The neoplastic cells were positive for p16.", + "The neoplastic cells were positive for TTF-1 with a nuclear staining pattern.", + "The neoplastic cells were negative for cytokeratin 5/6.", + "The neoplastic cells were negative for CAM 5.2.", + "The neoplastic cells were negative for p63.", + "The neoplastic cells were negative for chromogranin.", + "The neoplastic cells were negative for CD56.", + "The neoplastic cells were negative for EBV by in-situ hybridization.", + "The tumor was positive for HPV16.", + "The tumor was negative for HPV18.", + "The tumor was negative for HPV31.", + "The tumor was negative for HPV33.", + "The tumor was negative for HPV35.", + "The tumor was negative for HPV39.", + "The tumor was negative for HPV45.", + "The tumor was negative for HPV51.", + "The tumor was negative for HPV52.", + "The tumor was negative for HPV56.", + "The tumor was negative for HPV59.", + "The tumor was negative for HPV66.", + "The tumor was negative for HPV68.", + "The tumor was staged T1N2cM0.", + "The tumor was stage IVA.", + "A percutaneous endoscopic gastrostomy tube (PEG) was placed before the beginning of treatment.", + "The PEG tube was placed to meet his nutritional and hydration needs during treatment.", + "The patient received four cycles of chemotherapy at 21 day-intervals.", + "The chemotherapy regimen consisted of cisplatin 75 mg/m2 on day one.", + "The chemotherapy regimen consisted of etoposide 80 mg/m2 on days one to three.", + "On cycle two, day eight, he started radiotherapy to the oropharynx and involved neck nodes.", + "He received a dose of 70 Gray (2 Gy/fraction) over a seven week-period.", + "During the concomitant phase of chemo-radiation, the patient experienced grade IV mucositis.", + "During the concomitant phase of chemo-radiation, the patient experienced grade II nausea.", + "During the concomitant phase of chemo-radiation, the patient experienced dehydration.", + "Due to grade III neutropenia, the dose of cisplatin and etoposide was reduced by 25% during the last cycle of chemotherapy.", + "Three months after completion of therapy, a PET/CT showed complete resolution of the tumor.", + "Three months after completion of therapy, a PET/CT showed complete resolution of the metastatic lymph nodes.", + "Three months after completion of therapy, there was no evidence of distant metastasis.", + "The patient had complete resolution of his mucositis.", + "The patient was able to resume a full oral diet.", + "The PEG tube was removed." + ], + "summary": "We present a rare case of a 56-year-old man who presented with a three-month history of an enlarging left-sided neck mass. Imaging was consistent with a soft tissue density at the left tongue base, left level IIB nodal conglomerate, and multiple bilateral cervical lymph nodes, without evidence of distant metastasis. The patient underwent a core biopsy of the left neck level II node which read as a poorly differentiated neuroendocrine carcinoma consistent with small cell carcinoma. Polymerase chain reaction revealed that the tumor was positive for HPV16. The tumor was staged T1N2cM0 (stage IVA). He went on to receive four cycles of cisplatin and etoposide. On cycle two, he started radiotherapy to the oropharynx and involved neck nodes. He received a dose of 70 Gray (2 Gy/fraction) over a seven week-period. During the concomitant phase of chemo-radiation, the patient experienced grade IV mucositis, grade II nausea, and dehydration for which he received additional outpatient fluid and electrolyte replacement. Three months after completion of therapy, a PET/CT showed complete resolution of the tumor and metastatic lymph nodes along with no evidence of distant metastasis.", + "summary_subclaims": [ + "The patient was a 56-year-old man.", + "He had a three-month history of an enlarging left-sided neck mass.", + "Imaging was consistent with a soft tissue density at the left tongue base.", + "Imaging showed a left level IIB nodal conglomerate.", + "Imaging showed multiple bilateral cervical lymph nodes.", + "There was no evidence of distant metastasis.", + "A core biopsy of the left neck level II node was performed.", + "The biopsy read as a poorly differentiated neuroendocrine carcinoma consistent with small cell carcinoma.", + "Polymerase chain reaction revealed that the tumor was positive for HPV16.", + "The tumor was staged T1N2cM0.", + "The tumor stage was stage IVA.", + "The patient received four cycles of cisplatin and etoposide.", + "On cycle two, he started radiotherapy to the oropharynx and involved neck nodes.", + "He received a dose of 70 Gray (2 Gy/fraction) over a seven week-period.", + "During chemo-radiation, the patient experienced grade IV mucositis.", + "During chemo-radiation, the patient experienced grade II nausea.", + "The patient experienced dehydration during chemo-radiation.", + "He received additional outpatient fluid and electrolyte replacement.", + "Three months after completion of therapy, a PET/CT showed complete resolution of the tumor.", + "Three months after completion of therapy, a PET/CT showed complete resolution of the metastatic lymph nodes.", + "There was no evidence of distant metastasis on the PET/CT." + ] + }, + { + "id": "multiclinsum_test_2532_en.txt", + "fulltext": "A 74-year-old woman presented with a painless anterior neck swelling since 2 months. It was progressively increasing in size and was associated with dysphagia, which was non-specific to fluid or solid. A gradual reduction in the appetite and oral intake with worsening dysphagia lead to a significant weight loss within this short period of time. A few weeks prior to the presentation, the patient noticed that her voice started to become hoarse with occasional noisy breathing and shortness of breath. She had no history of neck irradiation or family members with thyroid cancer or any kind of malignancy. During physical examination, she appeared to be cachexic and mildly tachypnoeic with audible biphasic stridor. There was a palpable multilobulated thyroid mass that was hard in consistency. The largest mass was located on the right lobe measuring about 5 cm x 4 cm and extending retrosternally. The trachea was not deviated; however, the normal laryngeal crepitus sign was absent. Nasoendoscopy finding was unremarkable, while laryngoscopy revealed right vocal cord palsy in paramedian position. A panendoscopy was carried out with a negative finding.\nFine needle aspiration for cytology (FNAC) revealed a colloid goiter with the presence of malignant cells. Computed tomography (CT) scan revealed the presence of a thyroid mass involving bilateral lobes and isthmus with bilateral cervical lymphadenopathy with evidence of lung metastases .\nOtherwise, no other features from the imaging could suggest the primary site of the lesion. While the treatment plan was carried out, the patient developed progressively worsening obstructive airway symptoms requiring an emergency tracheostomy. Total thyroidectomy was successfully performed in the following week once her general medical condition had been optimized. Intraoperatively, there were multiple, locally invasive thyroid nodules mainly of the left lobe infiltrating the anterior wall of the trachea into the lumen and laterally to the right lobe with tracheal ring defect. Selective neck dissection was performed to remove the paratracheal and jugulo-omohyoid groups of the lymph node bilaterally.\nHistopathological analysis of the lesion showed a moderately differentiated squamous cell carcinoma (SCC) whereby the tumor tissue was composed entirely of malignant squamous cells .\nThese cells were cohesive and arranged in sheets, nests, cords, islands and trabeculae pattern. These malignant cells exhibited large, pleomorphic, hyperchromatic to vesicular nuclei with large, prominent eosinophilic nucleoli and abundant eosinophilic cytoplasm. Individual keratinization and intercellular bridges were noted as well as tumor cell spindling . Mitotic figures were brisk, including the atypical form, and tumor necrosis was also noted. This tumor was seen infiltrating the surrounding skeletal muscle bundles and destroying the thyroid gland parenchyma.\nThe patient was closely observed in the intensive care unit (ICU) post operatively and showed good progress. However, 2 weeks post operatively, she contracted a hospital-acquired pneumonia which put her oncological treatment on hold. The infection unfortunately progressed into sepsis and eventually claimed her life a week later.", + "fulltext_subclaims": [ + "The patient is a 74-year-old woman.", + "She had a painless anterior neck swelling since 2 months.", + "The neck swelling was progressively increasing in size.", + "The swelling was associated with dysphagia.", + "The dysphagia was non-specific to fluid or solid.", + "A gradual reduction in appetite and oral intake occurred.", + "Worsening dysphagia led to significant weight loss.", + "The patient noticed hoarseness of voice a few weeks prior to presentation.", + "She had occasional noisy breathing.", + "She had shortness of breath.", + "She had no history of neck irradiation.", + "She had no family members with thyroid cancer.", + "She had no family members with any kind of malignancy.", + "During physical examination, she appeared cachexic.", + "During physical examination, she was mildly tachypnoeic.", + "There was audible biphasic stridor.", + "There was a palpable multilobulated thyroid mass.", + "The thyroid mass was hard in consistency.", + "The largest mass was located on the right lobe.", + "The largest mass measured about 5 cm x 4 cm.", + "The mass extended retrosternally.", + "The trachea was not deviated.", + "The normal laryngeal crepitus sign was absent.", + "Nasoendoscopy findings were unremarkable.", + "Laryngoscopy revealed right vocal cord palsy in paramedian position.", + "A panendoscopy was carried out.", + "Panendoscopy findings were negative.", + "Fine needle aspiration for cytology (FNAC) revealed a colloid goiter.", + "FNAC showed the presence of malignant cells.", + "Computed tomography (CT) scan revealed a thyroid mass involving bilateral lobes and isthmus.", + "CT scan showed bilateral cervical lymphadenopathy.", + "CT scan showed evidence of lung metastases.", + "No other features from the imaging could suggest the primary site of the lesion.", + "The patient developed progressively worsening obstructive airway symptoms.", + "An emergency tracheostomy was required.", + "Total thyroidectomy was successfully performed.", + "The surgery was performed in the following week.", + "The patient's general medical condition was optimized before surgery.", + "Intraoperatively, there were multiple, locally invasive thyroid nodules.", + "The nodules mainly involved the left lobe.", + "The nodules infiltrated the anterior wall of the trachea into the lumen.", + "The nodules extended laterally to the right lobe.", + "There was a tracheal ring defect.", + "Selective neck dissection was performed.", + "The paratracheal lymph node groups were removed bilaterally.", + "The jugulo-omohyoid lymph node groups were removed bilaterally.", + "Histopathological analysis showed a moderately differentiated squamous cell carcinoma (SCC).", + "The tumor tissue was composed entirely of malignant squamous cells.", + "The malignant cells were cohesive and arranged in sheets, nests, cords, islands, and trabeculae pattern.", + "The malignant cells exhibited large, pleomorphic, hyperchromatic to vesicular nuclei.", + "The malignant cells had large, prominent eosinophilic nucleoli.", + "The malignant cells had abundant eosinophilic cytoplasm.", + "Individual keratinization was noted.", + "Intercellular bridges were noted.", + "Tumor cell spindling was noted.", + "Mitotic figures were brisk, including atypical forms.", + "Tumor necrosis was noted.", + "The tumor infiltrated surrounding skeletal muscle bundles.", + "The tumor destroyed the thyroid gland parenchyma.", + "The patient was closely observed in the ICU post operatively.", + "The patient showed good progress in the ICU.", + "Two weeks post operatively, she contracted hospital-acquired pneumonia.", + "The infection progressed into sepsis.", + "The patient's oncological treatment was put on hold.", + "The patient died a week after the infection progressed into sepsis." + ], + "summary": "A 74-year-old woman presented with a rapidly progressive neck swelling, with hoarseness and compressive symptoms. Physical examination revealed a multilobulated firm thyroid mass with unilateral vocal cord palsy. Histopathological findings confirmed the diagnosis of SCC while radiological investigations and panendoscopy findings ruled out the possibility of other primary tumors. A surgical intervention was performed; however, the patient eventually succumbed to death prior to undergoing an oncological treatment.", + "summary_subclaims": [ + "A 74-year-old woman presented with a rapidly progressive neck swelling.", + "The patient had hoarseness and compressive symptoms.", + "Physical examination revealed a multilobulated firm thyroid mass.", + "Histopathological findings confirmed the diagnosis of SCC.", + "Radiological investigations and panendoscopy findings ruled out the possibility of other primary tumors.", + "A surgical intervention was performed.", + "The patient eventually succumbed to death prior to undergoing an oncological treatment." + ] + }, + { + "id": "multiclinsum_test_926_en.txt", + "fulltext": "A 69-year-old Japanese woman was referred to our hospital with a chief complaint of abdominal discomfort. She had no history of smoking and was a social drinker. She also had a history of hyperlipidemia, depression, and uterine myoma. Body temperature was normal. Physical examination revealed no swelling of superficial lymph nodes. The patient had regular bowel movements with normal stools. She had no B symptoms, including fever, night sweats, or weight loss. Laboratory data were unremarkable: white blood cell (WBC) count, 5890/µL; hemoglobin, 13.2 g/dL; platelet count, 254,000/µL; and lactate dehydrogenase (LDH) level, 217 U/L. Tumor markers, including carcinoembryonic antigen and carbohydrate antigen 19-9, were within normal ranges. The serum soluble interleukin-2 receptor (sIL-2R) level was also within normal ranges.\nAbdominal ultrasonography revealed a well-circumscribed hypoechoic mass, contiguous with the proper muscle layer, approximately 70 mm in size, located at the middle stomach on the lesser curve . Contrast-enhanced CT of the abdomen demonstrated an extraluminal tumor with heterogeneous enhancement at the middle stomach on the lesser curve, accompanied with one swollen lymph node approximately 10 mm in size and several small lymph nodes in the perigastric region . These lymph nodes were flat; therefore, we considered them to be non-metastatic. No liver metastasis, peritoneal dissemination, pleural fluid, ascites, or splenomegaly was observed. Endoscopy indicated compression of the anterior wall of the gastric body along with normal mucosa . Several biopsy specimens were taken, which showed evidence of erosive hyperplastic gastritis. Endoscopic ultrasonography and endoscopic ultrasound-guided fine needle aspiration were not performed for the diagnosis because a SMT greater than 50 mm in size is an indication for surgery regardless of the preoperative definitive diagnosis .\nSurgical exploration of the abdomen revealed no evidence of ascites or metastasis to the liver or peritoneum. An extraluminal tumor arising from the middle body of the stomach on the lesser curve was noted. The tumor was removed via wedge resection. Soft and slightly swollen lymph nodes, which were compatible with the lymph nodes noted in the preoperative CT, were found near the main tumor in the fatty tissue at the lesser curvature of the stomach. An excisional biopsy of the largest lymph node, likely compatible with the swollen lymph node seen in the preoperative CT, was performed for the diagnosis. At this point, we believed these lymph nodes to represent reactive lymphadenopathy.\nThe resected specimen was 80 × 60 × 50 mm in size. The tumor grew exophytically. The cut surface of the tumor revealed a well-circumscribed yellowish-white solid mass . Hematoxylin–eosin staining disclosed a bundle-like growth of the spindle-shaped tumor cells with acidophilic cytoplasm . These were composed predominantly of tumor cells arranged haphazardly (Antoni type B) and secondarily of tumor cells with nuclear palisading (Antoni type A). A peritumoral lymphoid cuff was recognized . The mitotic count was 0 to 1 per 50 high-power fields (HPFs). The tumor contained no necrosis and atypical mitosis was not identified. The resection margins were free of tumor cells. Immunohistochemical staining revealed that the tumor was negative for KIT, CD34, and desmin and positive for S-100 protein . The MIB-1 labeling index of the tumor cells was 1% to 2%. Hematoxylin–eosin staining of the lymph node showed nodular proliferation of atypical lymphoid cells composed predominantly of centrocytes with admixed scattered centroblasts . Immunohistochemical staining revealed that the lymph node was positive for bcl-2, CD20, and CD79a and negative for CD3 and CD30 . These histopathological and immunohistochemical findings were consistent with a gastric schwannoma and FL. The centroblasts were noted 2 to 3 per 50 HPFs; therefore, histological grading of FL was Grade 1 .\nThe patient had an uneventful postoperative course and was discharged from our hospital on postoperative day 9. Postoperative positron emission tomography (PET) revealed no significant accumulation of 18F-fluorodeoxyglucose. Bone marrow aspiration indicated no bone marrow invasion of FL. The patient was diagnosed with a grading of stage I according to the Ann Arbor classification. The Groupe d’Etude des Lymphomes Folliculaires (GELF) criteria were applicable as low-tumor burden FL and the patient was asymptomatic; therefore, the watchful waiting approach was decided upon as follow-up . The patient is doing well without recurrence of either the gastric schwannoma or FL 28 months postsurgery.", + "fulltext_subclaims": [ + "The patient was a 69-year-old Japanese woman.", + "She had a history of hyperlipidemia.", + "She had a history of depression.", + "She had a history of uterine myoma.", + "The patient had no history of smoking.", + "The patient was a social drinker.", + "Physical examination revealed no swelling of superficial lymph nodes.", + "The patient had regular bowel movements with normal stools.", + "She had no B symptoms, including fever, night sweats, or weight loss.", + "The white blood cell count was 5890/µL.", + "The hemoglobin level was 13.2 g/dL.", + "The platelet count was 254,000/µL.", + "The lactate dehydrogenase level was 217 U/L.", + "Tumor markers, including carcinoembryonic antigen and carbohydrate antigen 19-9, were within normal ranges.", + "The serum soluble interleukin-2 receptor level was within normal ranges.", + "Abdominal ultrasonography revealed a well-circumscribed hypoechoic mass, contiguous with the proper muscle layer, approximately 70 mm in size, located at the middle stomach on the lesser curve.", + "Contrast-enhanced CT of the abdomen demonstrated an extraluminal tumor with heterogeneous enhancement at the middle stomach on the lesser curve.", + "Contrast-enhanced CT showed one swollen lymph node approximately 10 mm in size.", + "Contrast-enhanced CT showed several small lymph nodes in the perigastric region.", + "These lymph nodes were flat.", + "We considered the lymph nodes to be non-metastatic.", + "No liver metastasis was observed.", + "No peritoneal dissemination was observed.", + "No pleural fluid was observed.", + "No ascites was observed.", + "No splenomegaly was observed.", + "Endoscopy indicated compression of the anterior wall of the gastric body.", + "Endoscopy showed normal mucosa.", + "Several biopsy specimens were taken, which showed evidence of erosive hyperplastic gastritis.", + "Endoscopic ultrasonography and endoscopic ultrasound-guided fine needle aspiration were not performed for the diagnosis.", + "A submucosal tumor greater than 50 mm in size is an indication for surgery regardless of the preoperative definitive diagnosis.", + "Surgical exploration of the abdomen revealed no evidence of ascites.", + "Surgical exploration revealed no metastasis to the liver or peritoneum.", + "An extraluminal tumor arising from the middle body of the stomach on the lesser curve was noted.", + "The tumor was removed via wedge resection.", + "Soft and slightly swollen lymph nodes, compatible with the lymph nodes noted in the preoperative CT, were found near the main tumor.", + "An excisional biopsy of the largest lymph node was performed for the diagnosis.", + "We believed these lymph nodes to represent reactive lymphadenopathy.", + "The resected specimen was 80 × 60 × 50 mm in size.", + "The tumor grew exophytically.", + "The cut surface of the tumor revealed a well-circumscribed yellowish-white solid mass.", + "Hematoxylin–eosin staining disclosed a bundle-like growth of the spindle-shaped tumor cells with acidophilic cytoplasm.", + "The tumor was composed predominantly of tumor cells arranged haphazardly (Antoni type B).", + "The tumor was composed secondarily of tumor cells with nuclear palisading (Antoni type A).", + "A peritumoral lymphoid cuff was recognized.", + "The mitotic count was 0 to 1 per 50 high-power fields.", + "The tumor contained no necrosis.", + "Atypical mitosis was not identified.", + "The resection margins were free of tumor cells.", + "The tumor was negative for KIT.", + "The tumor was negative for CD34.", + "The tumor was negative for desmin.", + "The tumor was positive for S-100 protein.", + "The MIB-1 labeling index of the tumor cells was 1% to 2%.", + "Hematoxylin–eosin staining of the lymph node showed nodular proliferation of atypical lymphoid cells composed predominantly of centrocytes with admixed scattered centroblasts.", + "The lymph node was positive for bcl-2.", + "The lymph node was positive for CD20.", + "The lymph node was positive for CD79a.", + "The lymph node was negative for CD3.", + "The lymph node was negative for CD30.", + "These histopathological and immunohistochemical findings were consistent with a gastric schwannoma.", + "These histopathological and immunohistochemical findings were consistent with follicular lymphoma.", + "The centroblasts were noted 2 to 3 per 50 high-power fields.", + "Histological grading of follicular lymphoma was Grade 1.", + "Postoperative positron emission tomography revealed no significant accumulation of 18F-fluorodeoxyglucose.", + "Bone marrow aspiration indicated no bone marrow invasion of follicular lymphoma.", + "The patient was diagnosed with stage I according to the Ann Arbor classification.", + "The Groupe d’Etude des Lymphomes Folliculaires (GELF) criteria were applicable as low-tumor burden follicular lymphoma.", + "The patient was asymptomatic.", + "The watchful waiting approach was decided upon as follow-up.", + "The patient is doing well without recurrence of either the gastric schwannoma or follicular lymphoma 28 months postsurgery." + ], + "summary": "A 69-year-old Japanese woman was referred to our hospital with a chief complaint of abdominal discomfort. Contrast-enhanced computed tomography (CT) of the abdomen revealed an extraluminal tumor with heterogeneous enhancement at the middle stomach on the lesser curve, accompanied with one swollen lymph node approximately 10 mm in size and several small lymph nodes in the perigastric region. These lymph nodes were flat; therefore, we considered them to be non-metastatic. The main tumor was removed via wedge resection. Soft and slightly swollen lymph nodes, which were compatible with the lymph nodes noted in the preoperative CT, were found near the main tumor in the fatty tissue at the lesser curvature of the stomach. An excisional biopsy of the largest lymph node was performed for the diagnosis. Based on pathological findings, a diagnosis of gastric schwannoma and follicular lymphoma (FL) was confirmed. The patient is doing well without recurrence of either the gastric schwannoma or FL 28 months postsurgery.", + "summary_subclaims": [ + "The patient is a 69-year-old Japanese woman.", + "The patient was referred to the hospital with a chief complaint of abdominal discomfort.", + "Contrast-enhanced CT of the abdomen revealed an extraluminal tumor with heterogeneous enhancement at the middle stomach on the lesser curve.", + "The tumor was accompanied by one swollen lymph node approximately 10 mm in size.", + "The tumor was accompanied by several small lymph nodes in the perigastric region.", + "The lymph nodes were flat.", + "The main tumor was removed via wedge resection.", + "Soft and slightly swollen lymph nodes compatible with the preoperative CT findings were found near the main tumor.", + "An excisional biopsy of the largest lymph node was performed.", + "The pathological findings confirmed a diagnosis of gastric schwannoma.", + "The pathological findings confirmed a diagnosis of follicular lymphoma.", + "The patient is doing well without recurrence of either the gastric schwannoma or follicular lymphoma.", + "The patient is 28 months postsurgery." + ] + }, + { + "id": "multiclinsum_test_1105_en.txt", + "fulltext": "An 18-day-old female was admitted to the paediatric intensive care unit because of a heart murmur and weak femoral pulses. The patient was in a good clinical condition with spontaneous breathing on room air and normal vital signs, except for a blood pressure gradient of 30 mmHg between the upper and the lower extremities. A transthoracic two-dimensional echocardiography was performed and confirmed the suspected diagnosis of aortic coarctation, with a systolic pressure gradient of 30 mmHg and a closed arterial duct . In addition, a total retrograde perfusion of the left circumflex coronary artery (LCX) was found, without visible ostial blood flow at the left aortic sinus (, online, Video S1). The left ventricle had a normal ejection fraction without regional wall abnormalities or mitral valve regurgitation. Because of uncertainty regarding the anatomy, a coronary angiography was performed, showing no left main coronary artery, but a single right coronary artery (RCA) arising from the aorta. The LCX was perfused retrogradely via collaterals of a normal right posterior descending artery and it reached the lateral wall of the ascending aorta, not flowing into it but into the right pulmonary artery (RPA) (, online, Video S2). Arising from the LCX, small branches of a rudimentary left anterior descending artery were seen. The pulmonary artery pressure was normal.\nAt 23 days of age, surgery was performed with resection of the aortic coarctation, end-to-end anastomosis, and reimplantation of the left coronary artery (LCA) into the posterior aortic sinus, using a button technique without stretching or torsion of the coronary artery (, online, Video S3). The RPA defect was closed with a xenopericardial patch. On post-operative Day 4, the patient exhibited recurrent episodes of supraventricular tachycardia, which were successfully treated with flecainide. After surgery, routine coronary angiography was performed, showing normal, antegrade flow into the LCA without stenosis . The girl recovered well from the operation and was discharged home soon with normal troponin values.", + "fulltext_subclaims": [ + "An 18-day-old female was admitted to the paediatric intensive care unit because of a heart murmur and weak femoral pulses.", + "The patient was in a good clinical condition with spontaneous breathing on room air.", + "The patient had normal vital signs, except for a blood pressure gradient of 30 mmHg between the upper and the lower extremities.", + "A transthoracic two-dimensional echocardiography confirmed the suspected diagnosis of aortic coarctation.", + "The echocardiography showed a systolic pressure gradient of 30 mmHg.", + "The echocardiography showed a closed arterial duct.", + "A total retrograde perfusion of the left circumflex coronary artery (LCX) was found.", + "There was no visible ostial blood flow at the left aortic sinus.", + "The left ventricle had a normal ejection fraction.", + "There were no regional wall abnormalities.", + "There was no mitral valve regurgitation.", + "A coronary angiography showed no left main coronary artery.", + "A single right coronary artery (RCA) was seen arising from the aorta.", + "The LCX was perfused retrogradely via collaterals of a normal right posterior descending artery.", + "The LCX reached the lateral wall of the ascending aorta.", + "The LCX did not flow into the ascending aorta but into the right pulmonary artery (RPA).", + "Small branches of a rudimentary left anterior descending artery were seen arising from the LCX.", + "The pulmonary artery pressure was normal.", + "At 23 days of age, surgery was performed with resection of the aortic coarctation.", + "The surgery included an end-to-end anastomosis.", + "The surgery included reimplantation of the left coronary artery (LCA) into the posterior aortic sinus.", + "The reimplantation used a button technique without stretching or torsion of the coronary artery.", + "The RPA defect was closed with a xenopericardial patch.", + "On post-operative Day 4, the patient exhibited recurrent episodes of supraventricular tachycardia.", + "The supraventricular tachycardia was successfully treated with flecainide.", + "After surgery, routine coronary angiography showed normal, antegrade flow into the LCA.", + "After surgery, routine coronary angiography showed no stenosis.", + "The girl recovered well from the operation.", + "The girl was discharged home soon.", + "The girl had normal troponin values after surgery." + ], + "summary": "An 18-day-old female was admitted to the paediatric intensive care unit because of a heart murmur and weak femoral pulses. A transthoracic two-dimensional echocardiography was performed and confirmed suspected diagnosis of aortic coarctation. In addition, a total retrograde perfusion of the left circumflex coronary artery (LCX) was found, without visible flow through the ostium of the left coronary artery (LCA) into the aorta. A coronary angiography was performed, showing a single right coronary artery with a normal right posterior descending artery (RPD). Supplied by collaterals from the RPD, the LCX was perfused retrogradely, passing by the lateral wall of the ascending aorta without flowing into it, but into the right pulmonary artery. At 23 days of age, surgery was performed with resection of the aortic coarctation and reimplantation of the LCA into the posterior aortic wall.", + "summary_subclaims": [ + "The patient was an 18-day-old female.", + "The patient was admitted to the paediatric intensive care unit.", + "The admission was because of a heart murmur.", + "The admission was because of weak femoral pulses.", + "A transthoracic two-dimensional echocardiography was performed.", + "The echocardiography confirmed suspected diagnosis of aortic coarctation.", + "A total retrograde perfusion of the left circumflex coronary artery (LCX) was found.", + "There was no visible flow through the ostium of the left coronary artery (LCA) into the aorta.", + "A coronary angiography was performed.", + "The coronary angiography showed a single right coronary artery.", + "The right posterior descending artery (RPD) was normal.", + "The LCX was perfused retrogradely by collaterals from the RPD.", + "The retrograde perfusion passed by the lateral wall of the ascending aorta.", + "The retrograde perfusion did not flow into the ascending aorta.", + "The retrograde perfusion flowed into the right pulmonary artery.", + "Surgery was performed at 23 days of age.", + "The surgery included resection of the aortic coarctation.", + "The surgery included reimplantation of the LCA into the posterior aortic wall." + ] + }, + { + "id": "multiclinsum_test_2705_en.txt", + "fulltext": "A 31-year-old male patient referred to our clinic with a chronically draining lesion on his chin. His history revealed that he had this lesion for more than 5 months and had undergone two times surgery and received antibiotics for prolonged period of time.\nDental history revealed no pain or any dental symptoms but he recalls to a direct blunt trauma to the anterior mandibular region. The periapical radiograph showed a large radiolucent area around lower right first incisor. There was no electric or thermal pulp testing performed on the same tooth. Neither percussion nor palpation revealed any abnormality.\nThe tooth was treated with calcium hydroxide and glycerine and antibiotics for 14 days. After the initial filling of the root canal, an apicoectomy and sinus excision was performed. Three months postoperative control revealed no sinus fistula or exudates from chin or from the mucosa.", + "fulltext_subclaims": [ + "The patient is a 31-year-old male.", + "He has a chronically draining lesion on his chin.", + "The lesion has been present for more than 5 months.", + "He had two times surgery.", + "He received antibiotics for a prolonged period of time.", + "He recalls a direct blunt trauma to the anterior mandibular region.", + "The periapical radiograph showed a large radiolucent area around the lower right first incisor.", + "There was no electric or thermal pulp testing performed on the same tooth.", + "Neither percussion nor palpation revealed any abnormality.", + "The tooth was treated with calcium hydroxide and glycerine.", + "Antibiotics were given for 14 days.", + "An apicoectomy and sinus excision was performed.", + "Three months postoperative control revealed no sinus fistula.", + "Three months postoperative control revealed no exudates from the chin." + ], + "summary": "A 31-year-old male patient referred to us with a chronically draining lesion on his chin. The lesion previously was misdiagnosed by medical doctors and had undergone two times surgery with a focus on the skin lesion and had received antibiotic therapy for a prolonged period of time. After clinical and radiologic examination the dental origin of the lesion was evident and proper endodontic and surgical treatment was performed. Three months later, after the treatment, the lesion showed total healing and reoccurrence occurred.", + "summary_subclaims": [ + "The patient is a 31-year-old male.", + "The patient had a chronically draining lesion on his chin.", + "The lesion was previously misdiagnosed by medical doctors.", + "The patient had undergone two times surgery.", + "The patient had received antibiotic therapy for a prolonged period of time.", + "After clinical and radiologic examination the dental origin of the lesion was evident.", + "Proper endodontic and surgical treatment was performed.", + "Three months later, after the treatment, the lesion showed total healing.", + "Reoccurrence occurred." + ] + }, + { + "id": "multiclinsum_test_3305_en.txt", + "fulltext": "A 50-year-old man was admitted to our hospital for evolution of progressive dyspnea, paroxysmal nocturnal dyspnea, orthopnea and fatigue, and abdominal distension. These symptoms began 2 months earlier, when he was diagnosed at a different hospital with bacterial pneumonia complicated by bilateral parapneumonic effusion, which required drainage. His past medical history included bilateral lipoma, which was surgically treated 1 year prior to admission, and thyroiditis 3 years earlier. He reported regular moderate alcohol intake (100 g/wk) and that he had smoked 20 cigarettes a day for 30 years. The study protocol was approved by the ethics review board of the First Hospital of Jilin University (No. 2016-263). Informed written consent was obtained from the patient for publication of this case report and accompanying images.\n\nUpon admission, his respiratory rate was 20 breaths/min, pulse was 102 beats/min, and blood pressure was 98/65 mm Hg. Bleeding points were scattered in the abdominal skin and hemorrhagic purpura were around the eye orbit. Physical examination revealed jugular venous distention and abolition of bilateral basilar breath sounds based on pulmonary auscultation. There was no cardiac murmur; however, a third heart sound was heard.\n\nAn echocardiography test of the chest demonstrated small bilateral pleural effusions, 42 mm under the left 7th rib and 54 mm under the right 7th rib. Electrocardiography (ECG) demonstrated a sinus rhythm with a heart rate of 93 beats/min, poor R-wave progression in leads V1–V3 with right axis deviation, and low voltage criteria. Echocardiography revealed diffuse left ventricular hypertrophy (septal and free wall thickness of 17 and 14 mm, respectively) with normal ventricular cavity size (diastolic and systolic chamber diameters of 45 and 23 mm, respectively). Enlarged atria (35 × 50 × 45 mm), and mild mitral and tricuspid regurgitation were observed. The left ventricle was interpreted to have severe diastolic dysfunction (mitral E wave velocity = 0.8 m/s, A wave = 0.27 m/s, medial E/e′ = 20), as well as mildly impaired systolic function with an impaired ejection fraction of 54% based on 2-dimensional echocardiography. The early diastolic transmitral filling velocity to atrial filling velocity (E/A) ratio increased to 4.25. The ventricle wall was characteristic sparkling and of granular texture. The echocardiographic appearance of thickened ventricle accompanied with low QRS voltage in ECG was characteristic. These abnormalities were considered suggestive of amyloidosis. To further evaluate both myocardial and pericardial pathologies, cardiac magnetic resonance imaging (MRI) was performed on a 3.0-T MR scan system. The cardiac MRI showed diffuse, subendocardial delayed gadolinium enhancement.\n\nAdditional testing revealed troponin I was mildly elevated at 0.14 ng/mL (normal 0–0.034 ng/mL). Plasma N-terminal brain natriuretic peptide (NT-proBNP) was elevated at 15,000 pg/mL (normal 0–400 pg/mL). Serum electrophoresis failed to detect monoclonal gammopathy in the serum, but immunoelectrophoresis revealed free lambda light chains. Serum free light–chain (FLC) analysis showed an altered kappa/lambda ratio of 0.01, with lambda light chains increased at 1240 mg/L (normal 8.3–27.0 mg/L). Bence-Jones protein was not detected in the urine. Bone marrow examination confirmed benign monoclonal gammopathy with 8.5% plasma cells, and biopsy stained for Congo red was negative. There was no evidence of multiple myeloma on skeletal survey. Autoantibody screening was normal. The glomerular filtration ratios were normal with daily proteinuria. A periumbilical fat aspirate sample confirmed amyloidosis. The patient was finally diagnosed with AL amyloidosis with cardiac and skin involvement, and in stage III using the Mayo 2012 staging system.\n\nThe patient's therapeutic plan was to perform 3 cycles of therapy with bortezomib (1.3 mg/sqm/d) and dexamethasone (20 mg/d) administered on the 1st, 8th, 15th, and 22nd days of each 3-week course. Cyclophosphamide was subsequently administered on the 2nd, 9th, 16th, and 23rd days (300 mg/d). Unfortunately, 5 days after the second cycle of therapy with bortezomib, the NT-proBNP level increased from 15,000 to 31,100 pg/mL, and troponin I increased from 0.14 to 0.463 ng/mL. The patient died because of a fulminant syndrome characterized by infiltrative pulmonary disease with hemorrhage, severe pulmonary infection, and heart failure.", + "fulltext_subclaims": [ + "The patient was a 50-year-old man.", + "He was admitted for progressive dyspnea, paroxysmal nocturnal dyspnea, orthopnea, fatigue, and abdominal distension.", + "These symptoms began 2 months earlier.", + "He was diagnosed at a different hospital with bacterial pneumonia complicated by bilateral parapneumonic effusion.", + "The parapneumonic effusion required drainage.", + "His past medical history included bilateral lipoma, surgically treated 1 year prior to admission.", + "He had thyroiditis 3 years earlier.", + "He reported regular moderate alcohol intake of 100 g/wk.", + "He had smoked 20 cigarettes a day for 30 years.", + "The study protocol was approved by the ethics review board of the First Hospital of Jilin University (No. 2016-263).", + "Informed written consent was obtained from the patient for publication of this case report and accompanying images.", + "Upon admission, his respiratory rate was 20 breaths/min.", + "His pulse was 102 beats/min.", + "His blood pressure was 98/65 mm Hg.", + "Bleeding points were scattered in the abdominal skin.", + "Hemorrhagic purpura were around the eye orbit.", + "Physical examination revealed jugular venous distention.", + "Bilateral basilar breath sounds were abolished based on pulmonary auscultation.", + "A third heart sound was heard.", + "Echocardiography demonstrated small bilateral pleural effusions.", + "Electrocardiography showed a sinus rhythm with a heart rate of 93 beats/min.", + "Poor R-wave progression in leads V1–V3 with right axis deviation was observed.", + "Low voltage criteria were present on ECG.", + "Echocardiography revealed diffuse left ventricular hypertrophy.", + "The septal thickness was 17 mm.", + "The free wall thickness was 14 mm.", + "The left ventricular cavity size was normal.", + "Diastolic chamber diameter was 45 mm.", + "Systolic chamber diameter was 23 mm.", + "Enlarged atria were observed.", + "Mild mitral and tricuspid regurgitation were observed.", + "The left ventricle had severe diastolic dysfunction.", + "The left ventricle had mildly impaired systolic function with an ejection fraction of 54%.", + "The E/A ratio increased to 4.25.", + "The ventricle wall was characteristic sparkling and of granular texture.", + "The echocardiographic appearance of thickened ventricle accompanied with low QRS voltage in ECG was characteristic.", + "These abnormalities were considered suggestive of amyloidosis.", + "Cardiac MRI showed diffuse, subendocardial delayed gadolinium enhancement.", + "Troponin I was mildly elevated at 0.14 ng/mL.", + "Plasma NT-proBNP was elevated at 15,000 pg/mL.", + "Serum electrophoresis failed to detect monoclonal gammopathy.", + "Immunoelectrophoresis revealed free lambda light chains.", + "Serum FLC analysis showed an altered kappa/lambda ratio of 0.01.", + "Lambda light chains were increased at 1240 mg/L.", + "Bence-Jones protein was not detected in the urine.", + "Bone marrow examination confirmed benign monoclonal gammopathy with 8.5% plasma cells.", + "Congo red staining was negative.", + "There was no evidence of multiple myeloma on skeletal survey.", + "Autoantibody screening was normal.", + "Glomerular filtration ratios were normal with daily proteinuria.", + "A periumbilical fat aspirate sample confirmed amyloidosis.", + "The patient was diagnosed with AL amyloidosis with cardiac and skin involvement.", + "The stage was III using the Mayo 2012 staging system.", + "The therapeutic plan included 3 cycles of therapy with bortezomib and dexamethasone.", + "Bortezomib was administered at 1.3 mg/sqm/d on the 1st, 8th, 15th, and 22nd days of each 3-week course.", + "Dexamethasone was administered at 20 mg/d on the 1st, 8th, 15th, and 22nd days.", + "Cyclophosphamide was administered at 300 mg/d on the 2nd, 9th, 16th, and 23rd days.", + "Five days after the second cycle of therapy with bortezomib, NT-proBNP increased from 15,000 to 31,100 pg/mL.", + "Troponin I increased from 0.14 to 0.463 ng/mL.", + "The patient died because of a fulminant syndrome characterized by infiltrative pulmonary disease with hemorrhage, severe pulmonary infection, and heart failure." + ], + "summary": "Patient concerns:\nWe report a case of a 50-year-old man who was admitted with evolution of progressive dyspnea. Two months before the present admission, the patient was diagnosed with bacterial pneumonia complicated by bilateral parapneumonic effusion that required drainage.\n\nDiagnosis:\nElectrocardiography demonstrated poor R-wave progression in leads V1-V3 with right axis deviation and low voltage criteria. Echocardiography revealed diffuse left ventricular hypertrophy with normal ventricular cavity size, severe diastolic dysfunction, and sparkling and granular texture of the ventricle wall. Serum free light-chain analysis showed an altered kappa/lambda ratio of 0.01 with lambda light chains greatly elevated. A periumbilical fat aspirate sample confirmed amyloidosis. Bone marrow examination confirmed benign monoclonal gammopathy with 8.5% plasma cells, and biopsy stained for Congo red was negative.\n\nIntervention:\nA combination of bortezomib with cyclophosphamide and dexamethasone treatment was initiated.\n\nOutcome:\nUnfortunately, 5 days after the second therapy with bortezomib, the patient died.", + "summary_subclaims": [ + "The patient was a 50-year-old man.", + "The patient was admitted with evolution of progressive dyspnea.", + "Two months before the present admission, the patient was diagnosed with bacterial pneumonia.", + "Bacterial pneumonia was complicated by bilateral parapneumonic effusion.", + "Bilateral parapneumonic effusion required drainage.", + "Electrocardiography demonstrated poor R-wave progression in leads V1-V3.", + "Electrocardiography showed right axis deviation.", + "Electrocardiography showed low voltage criteria.", + "Echocardiography revealed diffuse left ventricular hypertrophy.", + "Echocardiography showed normal ventricular cavity size.", + "Echocardiography showed severe diastolic dysfunction.", + "Echocardiography showed sparkling and granular texture of the ventricle wall.", + "Serum free light-chain analysis showed an altered kappa/lambda ratio of 0.01.", + "Serum free light-chain analysis showed lambda light chains greatly elevated.", + "A periumbilical fat aspirate sample confirmed amyloidosis.", + "Bone marrow examination confirmed benign monoclonal gammopathy.", + "Bone marrow examination showed 8.5% plasma cells.", + "Biopsy stained for Congo red was negative.", + "A combination of bortezomib with cyclophosphamide and dexamethasone treatment was initiated.", + "The patient died 5 days after the second therapy with bortezomib." + ] + }, + { + "id": "multiclinsum_test_2055_en.txt", + "fulltext": "A 51-year-old male with intellectual disability presented to our hospital due to fever. He denied any pain or other symptoms, and his vital signs were normal. Laboratory values were as follows: 11,500/mm3 white blood cells, 12.3 g/dL hemoglobin, 5 mg/L C-reactive protein, 12 U/L aspartate aminotransferase, and 9 U/L alanine aminotransferase. Initially, he was diagnosed with aspiration pneumonia based on chest X-ray and blood examination. However, an abdominal X-ray examination suggested a foreign body , and a computed tomography (CT) scan revealed a toothbrush in the duodenum . No abnormal ascites fluid, free air, and abdominal abscess were observed, and it looked as if the toothbrush was stuck in the liver. An upper gastrointestinal endoscopy was performed immediately following the CT studies. It was observed in the second part of duodenum, and there was a granuloma around the handle part of the toothbrush at the duodenal bulb . Endoscopic removal was attempted using a polypectomy snare and biopsy forceps. However, the toothbrush was deeply embedded into the duodenal mucosa, so it could not be safely removed. This case was diagnosed as duodenal incarceration of the toothbrush, and it was removed by laparoscopic surgery, which is less invasive than open surgery. The surgical procedure was as follows . First, we found that the hepatic hilum and duodenal bulb were adhered tightly and could not be detached by peeling. Therefore, the toothbrush was difficult to remove by making an incision in the duodenal bulb. For that, the transverse and ascending colons were detached from the retroperitoneum to expose the C-loop of the duodenum in which the toothbrush was incarcerated. After that, an incision was made on the caudal side of the second part of the duodenum, and the toothbrush was removed through the incision . The extraction hole was closed using a barbed suture, and the procedure was completed. The operation time and estimated blood loss were 201 min and a little, respectively. The extracted toothbrush was 15 cm in length . The patient’s postoperative course was uneventful without complications and a postoperative CT showed no changes in the liver . During the postoperative course, no abnormal values of liver function were observed; these results were consistent with those of the preoperative blood examination.", + "fulltext_subclaims": [ + "The patient was a 51-year-old male with intellectual disability.", + "He presented to the hospital due to fever.", + "He denied any pain or other symptoms.", + "His vital signs were normal.", + "The white blood cell count was 11,500/mm3.", + "The hemoglobin level was 12.3 g/dL.", + "The C-reactive protein level was 5 mg/L.", + "The aspartate aminotransferase level was 12 U/L.", + "The alanine aminotransferase level was 9 U/L.", + "An abdominal X-ray suggested a foreign body.", + "A CT scan revealed a toothbrush in the duodenum.", + "No abnormal ascites fluid was observed.", + "No free air was observed.", + "No abdominal abscess was observed.", + "The toothbrush looked as if it was stuck in the liver.", + "An upper gastrointestinal endoscopy was performed.", + "The toothbrush was observed in the second part of the duodenum.", + "A granuloma was present around the handle part of the toothbrush at the duodenal bulb.", + "Endoscopic removal was attempted using a polypectomy snare and biopsy forceps.", + "The toothbrush was deeply embedded into the duodenal mucosa.", + "The toothbrush could not be safely removed.", + "The case was diagnosed as duodenal incarceration of the toothbrush.", + "The toothbrush was removed by laparoscopic surgery.", + "The surgical procedure was as follows.", + "The hepatic hilum and duodenal bulb were adhered tightly.", + "The toothbrush was difficult to remove by making an incision in the duodenal bulb.", + "The transverse and ascending colons were detached from the retroperitoneum.", + "The C-loop of the duodenum was exposed.", + "An incision was made on the caudal side of the second part of the duodenum.", + "The toothbrush was removed through the incision.", + "The extraction hole was closed using a barbed suture.", + "The operation time was 201 minutes.", + "The estimated blood loss was a little.", + "The extracted toothbrush was 15 cm in length.", + "The patient’s postoperative course was uneventful without complications.", + "A postoperative CT showed no changes in the liver.", + "No abnormal values of liver function were observed during the postoperative course.", + "The postoperative liver function results were consistent with those of the preoperative blood examination." + ], + "summary": "A 51-year-old male with intellectual disability presented to our hospital due to fever. Initially, he was diagnosed with aspiration pneumonia by chest X-ray and blood examination. However, abdominal X-ray examination suggested a foreign body, and a computed tomography scan revealed a toothbrush in the duodenum. Therefore, upper gastrointestinal endoscopy was immediately attempted to remove it, but it could not be safely removed because the handle part of the toothbrush seemed deeply embedded in the duodenal mucosa. Therefore, this case was diagnosed as duodenal incarceration of the toothbrush, and it was removed by laparoscopic surgery. The operation was performed safely, and the patient's postoperative course was good without any complications. The extracted toothbrush was 15 cm in length.", + "summary_subclaims": [ + "The patient is a 51-year-old male with intellectual disability.", + "The patient presented to the hospital due to fever.", + "Chest X-ray and blood examination initially diagnosed aspiration pneumonia.", + "Abdominal X-ray suggested a foreign body.", + "Computed tomography revealed a toothbrush in the duodenum.", + "Upper gastrointestinal endoscopy was immediately attempted to remove the toothbrush.", + "The toothbrush could not be safely removed by endoscopy.", + "The handle part of the toothbrush seemed deeply embedded in the duodenal mucosa.", + "The case was diagnosed as duodenal incarceration of the toothbrush.", + "The toothbrush was removed by laparoscopic surgery.", + "The operation was performed safely.", + "The patient's postoperative course was good without any complications.", + "The extracted toothbrush was 15 cm in length." + ] + }, + { + "id": "multiclinsum_test_2941_en.txt", + "fulltext": "A 73-year-old woman (height, 157 cm; weight, 43 kg) visited a physician 7 days before admission to our hospital for dizziness, loss of appetite, and fatigue, but no specific issues could be determined, and the patient returned home without receiving treatment. On the day of admission, she revisited the physician because she had a fever of 38°C and dyspnea. Her oxygen saturation was 86% in ambient room air, and nasopharyngeal swab polymerase chain reaction for SARS-Cov-2 revealed that she had COVID-19. The patient was transferred to our hospital under oxygen administration for respiratory management.\nWhen the patient arrived at our hospital, her oxygen saturation was 87% (blood pressure, 152/68 mmHg; heart rate, 73 bpm) with oxygen administered at 2 L/min via a nasal cannula. We changed the oxygen administration method to OxyMaskTM (Southmedic Inc., Barrie, ON, Canada) at 7 L/min, and her oxygen saturation increased to 92%. Subsequently, she was admitted to the intensive care unit. Although she had no underlying conditions that would increase her risk for severe COVID-19, shortly after admission, her oxygen saturation dropped to approximately 90% and her respiratory rate increased to 40/min. We decided to start high-flow nasal cannula therapy at 50 L/min, FIO2 50%.\nHer hemogram showed a white blood cell count of 7400/μl and hemoglobin 12.4 g/dl. Her blood biochemistry tests only showed mild elevation in transaminases (glutamic oxaloacetic transaminase, 46 U/l; glutamic pyruvic transaminase, 36 U/l), and her renal function tests and electrolytes were within the normal limits. Arterial blood gas analysis performed before high-flow oxygen therapy was suggestive of type 1 respiratory failure (pH, 7.496; PO2, 52.2 mmHg; PCO2, 28.5 mmHg). Initial chest computed tomography (CT) showed bilateral and peripheral predominant consolidation and an air bronchogram.\nShe was managed according to our institutional protocol (inhalational oxygen concentration, steroids, anticoagulation, tocilizumab, rehabilitation) and maintaining oxygen saturation 92%. Although she temporarily needed an FIO2 of 0.8 to maintain her peripheral oxygen saturation, we did not intubate her because she did not exert effort during ventilation, she strongly preferred not to be intubated, and her only symptom was lightheadedness when standing. On the 11th day of hospitalization, although her oxygen saturation decreased with light exertion but stabilized at rest in the supine position, we changed the oxygen administration method to OxyMaskTM 8 L/min. Although oxygen saturation was maintained when the patient was at rest and in the supine position, it dropped to lower than 80% when the patient was in the sitting position after, for instance, moving to a portable toilet. Moreover, more than 30 min was needed for oxygen saturation to increase even after starting high-flow oxygen therapy with fraction of inspiratory oxygen 0.5 or higher. However, SpO2 rapidly recovered when the patient was repositioned to the supine position. We suspected the presence of a right–left shunt, which increased with change in position, and asked the cardiologist to search for a PFO or ASD. We performed contrast-enhanced CT and echocardiography but could not find an intracardiac shunt. Afterward, although her oxygen saturation slightly decreased when she sat or stood, her oxygenation slowly improved, and she was discharged under home oxygen therapy with 0.5 L/min via a nasal cannula 28 days after admission.", + "fulltext_subclaims": [ + "The patient is a 73-year-old woman.", + "The patient's height is 157 cm.", + "The patient's weight is 43 kg.", + "The patient visited a physician 7 days before admission.", + "The patient reported dizziness, loss of appetite, and fatigue.", + "No specific issues could be determined during the visit 7 days before admission.", + "The patient returned home without receiving treatment.", + "On the day of admission, the patient revisited the physician.", + "The patient had a fever of 38°C on the day of admission.", + "The patient had dyspnea on the day of admission.", + "The patient's oxygen saturation was 86% in ambient room air.", + "Nasopharyngeal swab polymerase chain reaction for SARS-Cov-2 revealed that she had COVID-19.", + "The patient was transferred to the hospital under oxygen administration.", + "The patient's oxygen saturation was 87% at the hospital.", + "The patient's blood pressure was 152/68 mmHg.", + "The patient's heart rate was 73 bpm.", + "Oxygen was administered at 2 L/min via a nasal cannula.", + "The oxygen administration method was changed to OxyMaskTM at 7 L/min.", + "The patient's oxygen saturation increased to 92%.", + "The patient was admitted to the intensive care unit.", + "The patient had no underlying conditions that would increase her risk for severe COVID-19.", + "Her oxygen saturation dropped to approximately 90% shortly after admission.", + "Her respiratory rate increased to 40/min.", + "High-flow nasal cannula therapy was started at 50 L/min, FIO2 50%.", + "Her white blood cell count was 7400/μl.", + "Her hemoglobin was 12.4 g/dl.", + "Her transaminases were mildly elevated.", + "Her renal function tests were within the normal limits.", + "Her electrolytes were within the normal limits.", + "Arterial blood gas analysis was suggestive of type 1 respiratory failure.", + "Initial chest computed tomography showed bilateral and peripheral predominant consolidation.", + "Initial chest computed tomography showed an air bronchogram.", + "She was managed according to the institutional protocol.", + "The institutional protocol included inhalational oxygen concentration.", + "The institutional protocol included steroids.", + "The institutional protocol included anticoagulation.", + "The institutional protocol included tocilizumab.", + "The institutional protocol included rehabilitation.", + "Oxygen saturation was maintained at 92%.", + "She temporarily needed an FIO2 of 0.8 to maintain her peripheral oxygen saturation.", + "She was not intubated.", + "She did not exert effort during ventilation.", + "She strongly preferred not to be intubated.", + "Her only symptom was lightheadedness when standing.", + "On the 11th day of hospitalization, oxygen saturation decreased with light exertion.", + "On the 11th day of hospitalization, oxygen saturation stabilized at rest in the supine position.", + "The oxygen administration method was changed to OxyMaskTM 8 L/min.", + "Oxygen saturation dropped to lower than 80% when the patient was in the sitting position.", + "More than 30 min was needed for oxygen saturation to increase after starting high-flow oxygen therapy.", + "SpO2 rapidly recovered when the patient was repositioned to the supine position.", + "A right–left shunt was suspected.", + "The right–left shunt was suspected to increase with change in position.", + "Contrast-enhanced CT was performed.", + "Echocardiography was performed.", + "An intracardiac shunt was not found.", + "Oxygen saturation slightly decreased when she sat or stood.", + "Oxygenation slowly improved.", + "The patient was discharged under home oxygen therapy.", + "Home oxygen therapy was with 0.5 L/min via a nasal cannula.", + "The patient was discharged 28 days after admission." + ], + "summary": "A 73-year-old woman was diagnosed with severe COVID-19 pneumonia and was managed according to our institutional protocol. Although her oxygenation improved at rest, oxygen saturation dropped to lower than 80% when she was in the sitting position. She had no patent foramen ovale or other intracardiac shunts. She showed gradual improvement and was discharged under home oxygen therapy 28 days after admission.", + "summary_subclaims": [ + "The patient was a 73-year-old woman.", + "She was diagnosed with severe COVID-19 pneumonia.", + "She was managed according to our institutional protocol.", + "Her oxygenation improved at rest.", + "Oxygen saturation dropped to lower than 80% when she was in the sitting position.", + "She had no patent foramen ovale.", + "She had no other intracardiac shunts.", + "She showed gradual improvement.", + "She was discharged under home oxygen therapy.", + "She was discharged 28 days after admission." + ] + }, + { + "id": "multiclinsum_test_3032_en.txt", + "fulltext": "The patient, a 17-year-old female, reported ocular floaters in her left eye persisting for 1 day. The patient had an unremarkable medical and family history, devoid of any reported trauma. BCVA was 1.0 (decimal) in both eyes. Both eyes exhibited myopia, while no additional ocular abnormalities were detected in the right eye apart from myopia. The intraocular pressure was measured as 17 mmHg in the right eye and 18 mmHg in the left eye. The slit lamp examination revealed unremarkable anterior segments of both eyes accompanied by normal bilateral pupillary responses. C/D in the right eye was 0.4, whereas it measured 0.5 in the left eye.\n\nIn the left eye, CFP revealed indistinct optic disc margins and small patchy hemorrhage, whereas no evident abnormalities were observed in the right eye (Clarus 500, Carl Zeiss Meditec, Inc). FAF showed hypofluorescence in the hemorrhagic area of the left optic disc (Panoramic ophthalmoscope, Daytona P200T). The PHOMS on B-scan SD-OCT image of the left eye exhibited an ovoid shape and appeared as peripapillary hyperreflective bright regions on en-face Min-IP image which corresponded to B-scan SD-OCT findings. The active blood flow signal of PHOMS was detected on SD-OCT/OCTA images of the left eye (Cirrus HD-OCT 5000, Germany). The results should be consistent with the diagnosis of spontaneous hemorrhage of the left optic disc, PHOMS and ocular floaters in the left eye, binocular ametropia.", + "fulltext_subclaims": [ + "The patient is a 17-year-old female.", + "The patient reported ocular floaters in her left eye persisting for 1 day.", + "The patient had an unremarkable medical and family history.", + "The patient had no reported trauma.", + "BCVA was 1.0 (decimal) in both eyes.", + "Both eyes exhibited myopia.", + "No additional ocular abnormalities were detected in the right eye apart from myopia.", + "Intraocular pressure was measured as 17 mmHg in the right eye.", + "Intraocular pressure was measured as 18 mmHg in the left eye.", + "The slit lamp examination revealed unremarkable anterior segments of both eyes.", + "C/D in the right eye was 0.4.", + "C/D in the left eye was 0.5.", + "CFP revealed indistinct optic disc margins in the left eye.", + "CFP revealed small patchy hemorrhage in the left eye.", + "No evident abnormalities were observed in the right eye on CFP.", + "FAF showed hypofluorescence in the hemorrhagic area of the left optic disc.", + "The PHOMS on B-scan SD-OCT image of the left eye exhibited an ovoid shape.", + "The PHOMS appeared as peripapillary hyperreflective bright regions on en-face Min-IP image.", + "The active blood flow signal of PHOMS was detected on SD-OCT/OCTA images of the left eye.", + "The results should be consistent with the diagnosis of spontaneous hemorrhage of the left optic disc.", + "The results should be consistent with the diagnosis of PHOMS.", + "The results should be consistent with the diagnosis of ocular floaters in the left eye.", + "The results should be consistent with the diagnosis of binocular ametropia." + ], + "summary": "A 17-year-old female presented with complaints of experiencing floaters in the left eye for a duration of 1 day. Small patchy hemorrhage was observed in the left optic disc. The patients underwent the color fundus photograph (CFP), fundus autofluorescence (FAF), spectral-domain optical coherence tomography (SD-OCT), optical coherence tomography angiography (OCTA), and Minimum intensity projection (Min-IP) images.\n\nSmall patchy hemorrhage was observed in the left optic disc and FAF showed hypofluorescence. PHOMS on SD-OCT of the left eye showed an ovoid shape and manifested as peripapillary hyperreflective bright regions on en-face Min-IP image, the active blood flow signal of PHOMS was detected on SD-OCT/OCTA. C/D in the right eye was 0.4.", + "summary_subclaims": [ + "The patient is a 17-year-old female.", + "The patient experienced floaters in the left eye for 1 day.", + "Small patchy hemorrhage was observed in the left optic disc.", + "The patient underwent color fundus photograph.", + "The patient underwent fundus autofluorescence.", + "The patient underwent spectral-domain optical coherence tomography.", + "The patient underwent optical coherence tomography angiography.", + "The patient underwent Minimum intensity projection images.", + "FAF showed hypofluorescence.", + "PHOMS on SD-OCT of the left eye showed an ovoid shape.", + "PHOMS manifested as peripapillary hyperreflective bright regions on en-face Min-IP image.", + "The active blood flow signal of PHOMS was detected on SD-OCT/OCTA.", + "C/D in the right eye was 0.4." + ] + }, + { + "id": "multiclinsum_test_1879_en.txt", + "fulltext": "A 61-year-old African American male with past medical history of hypertension and schizophrenia presented to the emergency room following 2 episodes of syncope.\nHe reported 3 month history of progressive neck mass. Physical examination revealed a temperature of 37.7 degrees, blood pressure of 130/87 mmHg, pulse of 92 bpm, and respiratory rate of 17 bpm. There was extremely large left sided neck mass extending into the left axilla and multiple palpable left and right cervical lymph nodes. The lungs were clear to auscultation, and there was a 2/6 systolic ejection murmur heard best at the bases. The abdomen was soft and nontender, without palpable organomegaly. There was a 5x2 cm right gluteal non-tender, non-mobile mass with central ulceration and also a 2x2 cm spherical mass at the left upper back with small central ulceration. There was 2+ pitting edema of the lower extremities bilaterally. There was differential swelling of left upper extremity. Electrocardiogram showed normal sinus rhythm, left axis deviation, low voltage and mild t wave inversion in V2–V4 .\nInitial CT scan of the abdomen and pelvis showed diffuse metastatic disease of the visualized lower chest, abdomen and pelvis including superficial soft tissues, left kidney, and probable right kidney. There was diffuse confluent adenopathy and massive right inguinal lymphadenopathy, along with pronounced diffuse anasarca. There are multiple renal masses. There are solid masses arising off of the lateral aspect of the left kidney involving the upper, middle and lower lobe . The left kidney mass was described as an exophytic lesion. There was a mass along the anterior aspect of the heart that measures approximately 5 cm but incompletely visualized. CT head was negative.\nTransthoracic echocardiogram revealed a large mass measuring 4.8 cm x 3.0 cm extending from the apex to the mid RV cavity, and extending into the RV outflow tract stopping just short of the pulmonic valve . There was deformation of the RV free wall suggesting invasion of the myocardial wall and a malignant growth. There was mild RV enlargement, with normal function of the segments not involved in mass. There RA was mildly dilated with no mass seen, and there was no evidence of thrombus in the IVC. There was a small pericardial effusion without echocardiographic evidence of tamponade. A dedicated CT of the thorax revealed a mildly enlarged heart, and a filling defect in the RV measuring 6 cm extending to the apex and suspicious for malignancy .\nA core biopsy of the right superficial gluteal mass revealed a tumor arranged in solid nests having abundant eosinophilic cytoplasm, central nucleus and conspicuous nucleoli, with areas of coagulative tumor necrosis, and individual tumor cell exhibiting high-grade atypia with pleomorphism .\nOn immunohistochemistry, the tumor cells expressed pacytokeratin, PAX 8, vimentin and CD 10 (weakly). The tumor cells are negative for S 100, Melan-A and RCC. Immunostains for CD 117 and CK 7 were performed, however were uninterpretable due to tissue depletion. Morphology and immunohistochemical profile favor a metastatic poorly differentiated carcinoma of likely renal origin, with a possibility of an unclassified RCC. Oncology was consulted and they suggested a diffuse metastatic malignancy of primary renal origin with poor prognosis. Oncology advised that the patient should follow up in outpatient cancer clinic. Due to extent and burden of metastasis, patient and family members agreed to conservative management and patient was placed in hospice and comfort care with no further aggressive management. He was discharged from the hospital to hospice and to follow-up with the cancer clinic, although there were no records that he kept the appointments and he was lost to follow-up.", + "fulltext_subclaims": [ + "The patient is a 61-year-old African American male.", + "The patient has a past medical history of hypertension.", + "The patient has a past medical history of schizophrenia.", + "The patient presented to the emergency room following 2 episodes of syncope.", + "The patient reported a 3 month history of progressive neck mass.", + "Physical examination revealed a temperature of 37.7 degrees.", + "Physical examination revealed a blood pressure of 130/87 mmHg.", + "Physical examination revealed a pulse of 92 bpm.", + "Physical examination revealed a respiratory rate of 17 bpm.", + "There was extremely large left sided neck mass extending into the left axilla.", + "There were multiple palpable left and right cervical lymph nodes.", + "The lungs were clear to auscultation.", + "There was a 2/6 systolic ejection murmur heard best at the bases.", + "There was a 5x2 cm right gluteal non-tender, non-mobile mass with central ulceration.", + "There was 2+ pitting edema of the lower extremities bilaterally.", + "There was differential swelling of the left upper extremity.", + "Electrocardiogram showed normal sinus rhythm.", + "Electrocardiogram showed left axis deviation.", + "Electrocardiogram showed low voltage.", + "Electrocardiogram showed mild t wave inversion in V2–V4.", + "Initial CT scan of the abdomen and pelvis showed diffuse metastatic disease of the visualized lower chest, abdomen and pelvis.", + "There was diffuse confluent adenopathy.", + "There was massive right inguinal lymphadenopathy.", + "There were multiple renal masses.", + "There were solid masses arising off of the lateral aspect of the left kidney involving the upper, middle and lower lobe.", + "The left kidney mass was described as an exophytic lesion.", + "Transthoracic echocardiogram revealed a large mass measuring 4.8 cm x 3.0 cm extending from the apex to the mid RV cavity.", + "The mass extended into the RV outflow tract stopping just short of the pulmonic valve.", + "There was deformation of the RV free wall suggesting invasion of the myocardial wall and a malignant growth.", + "There was a small pericardial effusion without echocardiographic evidence of tamponade.", + "A dedicated CT of the thorax revealed a filling defect in the RV measuring 6 cm extending to the apex and suspicious for malignancy.", + "A core biopsy of the right superficial gluteal mass revealed a tumor arranged in solid nests having abundant eosinophilic cytoplasm, central nucleus and conspicuous nucleoli.", + "The tumor cells expressed pacytokeratin.", + "The tumor cells expressed PAX 8.", + "The tumor cells expressed vimentin.", + "The tumor cells expressed CD 10 (weakly).", + "The tumor cells are negative for S 100.", + "The tumor cells are negative for Melan-A.", + "The tumor cells are negative for RCC.", + "Morphology and immunohistochemical profile favor a metastatic poorly differentiated carcinoma of likely renal origin.", + "Oncology suggested a diffuse metastatic malignancy of primary renal origin with poor prognosis.", + "The patient and family members agreed to conservative management.", + "The patient was placed in hospice and comfort care with no further aggressive management.", + "The patient was discharged from the hospital to hospice." + ], + "summary": "A 61-year-old African American male with past medical history of hypertension and schizophrenia presented to the emergency room following 2 episodes of syncope and 3-month history of progressive neck mass. CT scan of neck, abdomen and pelvis showed bulky left cervical, supraclavicular and axillary lymph node, mass in anterior aspect of heart, and multiple solid left renal masses and probable right renal mass. Echocardiogram revealed a large RV mass with deformation of the RV free wall suggesting malignant growth. Core biopsy of the right superficial gluteal mass revealed a metastatic poorly differentiated carcinoma of likely renal origin, with a possibility of an unclassified RCC. Due to the extent and burden of metastasis, patient and family members agreed to conservative management and evaluation for hospice care.", + "summary_subclaims": [ + "The patient is a 61-year-old African American male.", + "The patient has a past medical history of hypertension.", + "The patient has a past medical history of schizophrenia.", + "The patient had 2 episodes of syncope.", + "The patient had a 3-month history of progressive neck mass.", + "CT scan showed bulky left cervical lymph node.", + "CT scan showed bulky left supraclavicular lymph node.", + "CT scan showed bulky left axillary lymph node.", + "CT scan showed a mass in the anterior aspect of the heart.", + "CT scan showed multiple solid left renal masses.", + "CT scan showed probable right renal mass.", + "Echocardiogram revealed a large RV mass.", + "Echocardiogram showed deformation of the RV free wall.", + "Echocardiogram suggested malignant growth.", + "Core biopsy of the right superficial gluteal mass revealed metastatic poorly differentiated carcinoma.", + "The core biopsy suggested likely renal origin of the metastatic carcinoma.", + "The core biopsy suggested the possibility of an unclassified RCC.", + "Due to the extent and burden of metastasis, the patient and family agreed to conservative management.", + "Due to the extent and burden of metastasis, the patient and family agreed to evaluation for hospice care." + ] + }, + { + "id": "multiclinsum_test_971_en.txt", + "fulltext": "A 33-year-old previously healthy male with no history of travel presented with abdominal pain, hematochezia, peripheral eosinophilia (6200 eos/µL), mesenteric, splenic, and portal vein thromboses resulting in ischemic colitis. Approximately 1 month prior to his hospitalization he had a self-limiting illness lasting five days with fever, nonproductive cough, myalgias, chills, and sweats. After resolution of this illness, he developed right upper thigh pruritus and bruising along with polyarthralgias which was unresponsive to prednisone. He did not have any rashes or angioedema. He was admitted for four days to an outside hospital after significant thrombocytopenia (20,000/μL) and eosinophilia (6200 eos/µL) were noted on CBC .\nUpon admission he was thought to have idiopathic thrombocytopenia purpura (ITP) and treated with intravenous immunoglobulin (IVIG), dexamethasone, and transfused one unit of platelets. Computed tomography (CT) showed nonocclusive right and left portal vein, mesenteric, and splenic vein thrombi. Bone marrow biopsy showed increased eosinophils accounting for 25% of granulocytes and 20% of total cells with no significant immunophenotypic abnormalities of myeloid cell populations and no abnormal B cell, T cell, or plasma cell populations identified. He was discharged from the outside hospital on warfarin after having completed a course of dexamethasone 40 mg daily for four days. His eosinophil count at discharge was 0 eos/µL.\nTwo weeks later, he again presented to the outside hospital after having severe abdominal pain, hematochezia, and fevers. Upon admission, noted to have eosinophil count of 5700 eos/µL. Endoscopy and subsequent pathology showed patchy eosinophilic infiltrates from esophagus through the colon along with evidence of ischemia. His eosinophil count continued to climb to a high of 10,000 eos/μL. He was placed on IV corticosteroids. Due to ongoing abdominal pain and concern for possible HES, he was transferred to our hospital for further evaluation and management.\nUpon admission, he developed worsening abdominal pain and contrast CT abdomen/pelvis revealed necrotic ascending colon and small bowel with ascending colon perforation, prompting emergent laparotomy, right hemicolectomy, and segmental small bowel resection. Pathology of the transverse colon showed increased eosinophils in the laminal propria with eosinophilic cryptitis along with eosinophils in the sigmoid colon. Additionally, pathology revealed thrombi involving submucosal, subserosal, and mesenteric elastic arteries and arterioles. No parasitic organisms were identified on any of the pathology slides. His troponin-I was negative (< 0.03 ng/mL) and his EKG showed normal sinus rhythm with no ST segment elevation or depression. His echocardiogram was normal. His chest radiographs were normal. Abdominal CT showed normal-sized spleen.\nPrimary and secondary causes of eosinophilia were excluded by hematology/oncology, infectious disease, and rheumatology .\nEvaluation also excluded genetically based myeloproliferative disorders and malignancies .\nThe patient was diagnosed with idiopathic HES and treated with 60 mg of IV methylprednisolone daily while continuing anticoagulation therapy as an inpatient. He was transitioned to 60 mg daily of prednisone prior to discharge while maintaining an eosinophil count of 0 eos/µL with no further evidence of coagulopathy. Shortly after discharge, benralizumab was started at 30 mg subcutaneously every 4 weeks for three doses then every 8 weeks. As benralizumab was started, he was simultaneously weaned off corticosteroids over the course of several months while maintaining peripheral eosinophil count of 0 eos/µL. After remaining asymptomatic for 10 months while on benralizumab, anticoagulation therapy was discontinued. His eosinophils have remained at 0 eos/µL and has had no further evidence of coagulopathy after 1 year of therapy with benralizumab. He will continue benralizumab indefinitely.", + "fulltext_subclaims": [ + "The patient is a 33-year-old previously healthy male.", + "He had no history of travel.", + "He presented with abdominal pain.", + "He had hematochezia.", + "He had peripheral eosinophilia of 6200 eos/µL.", + "He had mesenteric, splenic, and portal vein thromboses.", + "The thromboses resulted in ischemic colitis.", + "Approximately 1 month prior to hospitalization, he had a self-limiting illness lasting five days.", + "The illness included fever, nonproductive cough, myalgias, chills, and sweats.", + "After the illness, he developed right upper thigh pruritus.", + "He had bruising along with polyarthralgias.", + "The polyarthralgias were unresponsive to prednisone.", + "He did not have any rashes.", + "He did not have angioedema.", + "He was admitted to an outside hospital for four days.", + "He had significant thrombocytopenia of 20,000/μL.", + "He had eosinophilia of 6200 eos/µL.", + "He was thought to have idiopathic thrombocytopenia purpura.", + "He was treated with intravenous immunoglobulin.", + "He was treated with dexamethasone.", + "He was transfused one unit of platelets.", + "CT showed nonocclusive right and left portal vein thrombi.", + "CT showed nonocclusive mesenteric and splenic vein thrombi.", + "Bone marrow biopsy showed increased eosinophils accounting for 25% of granulocytes.", + "Bone marrow biopsy showed increased eosinophils accounting for 20% of total cells.", + "There were no significant immunophenotypic abnormalities of myeloid cell populations.", + "No abnormal B cell, T cell, or plasma cell populations were identified.", + "He was discharged on warfarin.", + "He had completed a course of dexamethasone 40 mg daily for four days.", + "His eosinophil count at discharge was 0 eos/µL.", + "Two weeks later, he presented with severe abdominal pain.", + "He had hematochezia.", + "He had fevers.", + "Endoscopy showed patchy eosinophilic infiltrates from esophagus through the colon.", + "Pathology showed evidence of ischemia.", + "His eosinophil count was 5700 eos/µL.", + "His eosinophil count climbed to 10,000 eos/µL.", + "He was placed on IV corticosteroids.", + "He was transferred to our hospital.", + "Upon admission, he developed worsening abdominal pain.", + "CT showed necrotic ascending colon.", + "CT showed necrotic small bowel.", + "CT showed ascending colon perforation.", + "He had emergent laparotomy.", + "He had right hemicolectomy.", + "He had segmental small bowel resection.", + "Pathology of the transverse colon showed increased eosinophils in the laminal propria.", + "Pathology showed eosinophilic cryptitis.", + "Pathology showed eosinophils in the sigmoid colon.", + "Pathology revealed thrombi involving submucosal, subserosal, and mesenteric elastic arteries and arterioles.", + "No parasitic organisms were identified.", + "His troponin-I was negative.", + "His EKG showed normal sinus rhythm.", + "His echocardiogram was normal.", + "His chest radiographs were normal.", + "Abdominal CT showed normal-sized spleen.", + "Primary and secondary causes of eosinophilia were excluded.", + "Genetically based myeloproliferative disorders were excluded.", + "Malignancies were excluded.", + "He was diagnosed with idiopathic HES.", + "He was treated with 60 mg of IV methylprednisolone daily.", + "He continued anticoagulation therapy.", + "He was transitioned to 60 mg daily of prednisone.", + "He had an eosinophil count of 0 eos/µL.", + "He had no further evidence of coagulopathy.", + "Benralizumab was started at 30 mg subcutaneously every 4 weeks for three doses.", + "Benralizumab was then started every 8 weeks.", + "He was weaned off corticosteroids over several months.", + "He maintained a peripheral eosinophil count of 0 eos/µL.", + "After 10 months on benralizumab, anticoagulation therapy was discontinued.", + "After 1 year of therapy with benralizumab, his eosinophils remained at 0 eos/µL.", + "He had no further evidence of coagulopathy.", + "He will continue benralizumab indefinitely." + ], + "summary": "A 33-year-old previously healthy male with no history of atopic disease presented with abdominal pain, hematochezia, peripheral eosinophilia as high as 10,000 eos/µL, right and left portal vein, mesenteric, and splenic vein thrombi with ischemic colitis resulting in hemicolectomy and small bowel resection. Despite an extensive workup for primary and secondary etiologies of hypereosinophilia by hematology/oncology, infectious disease, rheumatology and allergy/immunology, no other clear causes were identified, and the patient was diagnosed with idiopathic HES. His eosinophilia was successfully treated with high-dose oral corticosteroids (OCS) and subsequently transitioned to anti-IL-5-receptor therapy with benralizumab. He has continued this treatment for over a year with no recurrence of eosinophilia or thrombosis while on benralizumab.", + "summary_subclaims": [ + "The patient is a 33-year-old previously healthy male.", + "The patient has no history of atopic disease.", + "The patient presented with abdominal pain.", + "The patient presented with hematochezia.", + "The patient had peripheral eosinophilia as high as 10,000 eos/µL.", + "The patient had right and left portal vein thrombi.", + "The patient had mesenteric vein thrombi.", + "The patient had splenic vein thrombi.", + "The patient had ischemic colitis.", + "The patient underwent hemicolectomy.", + "The patient underwent small bowel resection.", + "No other clear causes of hypereosinophilia were identified.", + "The patient was diagnosed with idiopathic HES.", + "The patient's eosinophilia was successfully treated with high-dose oral corticosteroids.", + "The patient was transitioned to anti-IL-5-receptor therapy with benralizumab.", + "The patient has continued benralizumab treatment for over a year.", + "The patient has had no recurrence of eosinophilia while on benralizumab.", + "The patient has had no recurrence of thrombosis while on benralizumab." + ] + }, + { + "id": "multiclinsum_test_1912_en.txt", + "fulltext": "A 22-year-old woman presented with severe allergic conjunctivitis for one and a half years prior to her visit. Her symptoms included itching, foreign body sensation, tearing, and photophobia. Ocular examination revealed thickened lid margins, conjunctival hyperemia with moderate thick ropy discharge, cobblestone-like papillary reaction at the palpebral conjunctiva, and dense punctate corneal epithelial erosion in both eyes . Visual acuity was 20/40 in the right eye and 20/50 in the left eye. Apart from the eyes, she also had erythematous keratotic plaque at flexor areas, which was compatible with atopic dermatitis, and clinical symptoms of allergic rhinitis. She was diagnosed with AKC and was treated with 0.2% olopatadine hydrochloride once a day, 1% preservative-free methylprednisolone 4 times per day, and frequent preservative-free artificial tears. After 1 month of treatment, her condition had not improves; therefore, 20 mg of oral prednisone per day and 1% cyclosporine A twice daily were added. However, we were unable to stop oral and topical steroids due to wax and wane exacerbations for over a year. Her visual acuity varied from 20/25 to 20/70 depending on disease activity, which extremely disturbed her daily living activities. Other allergic conditions, including rhinitis and dermatitis, were well controlled by using oral antihistamine and topical steroids.\nDue to refractory AKC, we referred her to an allergy clinic for considering the role of SCIT. Allergology investigations showed positive skin prick tests to Dermatophagoides farinae (Der f), Dermatophagoides pteronyssinus (Der p), cat hair, and cockroach. The levels of IgE in peripheral blood were 1,636 kUA/L of total IgE, 58.2 kUA/L of specific IgE for Der p (class 5, strongly positive), 45.2 kUA/L of specific IgE for Der f (class 4, strongly positive), 0.51 kUA/L of specific IgE for German cockroach (class 1, weakly positive), and <0.35 kUA/L of specific IgE for cat (negative).\nAccording to the positive results of skin prick tests and serum-specific IgE in this patient, conventional SCIT for Der f and Der p was performed by using standardized Der f and Der p commercial extracts (ALK Laboratories, Port Washington, NY, USA). The conventional protocol for SCIT started with 0.1 mL of 10 AU/mL of each allergen extract, then the treatment dose was adjusted weekly until it reached the monthly maintenance dose at 0.5 mL of 1,000 AU/mL of each allergen extract within 12 weeks. The ocular symptoms and signs were significantly improved in terms of lid inflammation, conjunctival reactions, and punctate epithelial erosion on the corneas 2 months after initiation of SCIT, as shown in Figure . We were able to taper the patient off oral and topical steroids within 3 months and maintained with topical mast cell stabilizers and preservative-free tears, without any episodes of exacerbation. Her vision was maintained at 20/40 in the right eye and 20/50 in the left eye. Moreover, her skin and nasal conditions gradually improved. No adverse effects were noted during SCIT.", + "fulltext_subclaims": [ + "The patient is a 22-year-old woman.", + "She had allergic conjunctivitis for one and a half years prior to her visit.", + "Her symptoms included itching.", + "Her symptoms included foreign body sensation.", + "Her symptoms included tearing.", + "Her symptoms included photophobia.", + "Ocular examination revealed thickened lid margins.", + "Ocular examination revealed conjunctival hyperemia with moderate thick ropy discharge.", + "Ocular examination revealed cobblestone-like papillary reaction at the palpebral conjunctiva.", + "Ocular examination revealed dense punctate corneal epithelial erosion in both eyes.", + "Visual acuity was 20/40 in the right eye.", + "Visual acuity was 20/50 in the left eye.", + "She had erythematous keratotic plaque at flexor areas.", + "The plaque was compatible with atopic dermatitis.", + "She had clinical symptoms of allergic rhinitis.", + "She was diagnosed with AKC.", + "She was treated with 0.2% olopatadine hydrochloride once a day.", + "She was treated with 1% preservative-free methylprednisolone 4 times per day.", + "She was treated with frequent preservative-free artificial tears.", + "After 1 month of treatment, her condition had not improved.", + "20 mg of oral prednisone per day was added.", + "1% cyclosporine A twice daily was added.", + "We were unable to stop oral and topical steroids due to wax and wane exacerbations for over a year.", + "Her visual acuity varied from 20/25 to 20/70 depending on disease activity.", + "Other allergic conditions, including rhinitis and dermatitis, were well controlled by using oral antihistamine and topical steroids.", + "We referred her to an allergy clinic for considering the role of SCIT.", + "Allergology investigations showed positive skin prick tests to Dermatophagoides farinae.", + "Allergology investigations showed positive skin prick tests to Dermatophagoides pteronyssinus.", + "Allergology investigations showed positive skin prick tests to cat hair.", + "Allergology investigations showed positive skin prick tests to cockroach.", + "The levels of IgE in peripheral blood were 1,636 kUA/L of total IgE.", + "The levels of IgE in peripheral blood were 58.2 kUA/L of specific IgE for Der p.", + "The levels of IgE in peripheral blood were 45.2 kUA/L of specific IgE for Der f.", + "The levels of IgE in peripheral blood were 0.51 kUA/L of specific IgE for German cockroach.", + "The levels of IgE in peripheral blood were <0.35 kUA/L of specific IgE for cat.", + "Conventional SCIT for Der f and Der p was performed by using standardized Der f and Der p commercial extracts.", + "The conventional protocol for SCIT started with 0.1 mL of 10 AU/mL of each allergen extract.", + "The treatment dose was adjusted weekly until it reached the monthly maintenance dose at 0.5 mL of 1,000 AU/mL of each allergen extract.", + "The monthly maintenance dose was reached within 12 weeks.", + "The ocular symptoms and signs were significantly improved in terms of lid inflammation 2 months after initiation of SCIT.", + "The ocular symptoms and signs were significantly improved in terms of conjunctival reactions 2 months after initiation of SCIT.", + "The ocular symptoms and signs were significantly improved in terms of punctate epithelial erosion on the corneas 2 months after initiation of SCIT.", + "We were able to taper the patient off oral and topical steroids within 3 months.", + "The patient was maintained with topical mast cell stabilizers.", + "The patient was maintained with preservative-free tears.", + "There were no episodes of exacerbation.", + "Her vision was maintained at 20/40 in the right eye.", + "Her vision was maintained at 20/50 in the left eye.", + "Her skin and nasal conditions gradually improved.", + "No adverse effects were noted during SCIT." + ], + "summary": "A 22-year-old woman presented with severe allergic conjunctivitis for one and a half year. She failed to respond to conventional topical anti-allergic medications, topical corticosteroid, as well as topical cyclosporine A. Therefore, oral corticosteroids had to be prescribed to control the exacerbation for 1 year. Due to refractory AKC and to avoid long-term corticosteroid use, we referred her to an allergy clinic for considering the role of SCIT. Allergology investigations showed positive skin prick test and strongly elevated serum-specific IgE to Dermatophagoides farinae (Der f) and Dermatophagoides pteronyssinus (Der p). She received a conventional protocol of SCIT using Der f and Der p allergen extracts.", + "summary_subclaims": [ + "The patient is a 22-year-old woman.", + "She had severe allergic conjunctivitis for one and a half year.", + "She failed to respond to conventional topical anti-allergic medications.", + "She failed to respond to topical corticosteroid.", + "She failed to respond to topical cyclosporine A.", + "Oral corticosteroids had to be prescribed to control the exacerbation for 1 year.", + "We referred her to an allergy clinic for considering the role of SCIT.", + "Allergology investigations showed positive skin prick test to Dermatophagoides farinae.", + "Allergology investigations showed positive skin prick test to Dermatophagoides pteronyssinus.", + "Allergology investigations showed strongly elevated serum-specific IgE to Dermatophagoides farinae.", + "Allergology investigations showed strongly elevated serum-specific IgE to Dermatophagoides pteronyssinus.", + "She received a conventional protocol of SCIT using Der f and Der p allergen extracts." + ] + }, + { + "id": "multiclinsum_test_2080_en.txt", + "fulltext": "A 53-year-old man accidentally fell off a three-meter high scaffolding while working resulting in severe chest pain and shortness of breath. Upon arrival at the emergency department of our hospital, physical examination was the following: temperature, 36.8 ℃; blood pressure, 132/86 mmHg; heart rate,101 beats/min; oxygen saturation, 89% (without oxygen inhalation), left chest tenderness, pain on anteroposteria chest compression. Taken chest computed tomography (CT) , he was found with left 7th through 11th rib fractures with lower left lobe contusion and hemothorax measured about 10% of the chest. After treatment with oxygen, external fixation by band, and pain management, the symptoms were initially relieved, while the pain remained severe several hours later even after the use of pethidine. After consultation, he decided to undergo surgery.\nAs the left 7th and 8th anterior ribs and the 10th and 11th posterior ribs were dislocated, the patient was taken to the operating room. After the double lumen endotracheal intubation general anesthesia, the patient was placed in the right decubitus position. After skin preparation and draping, a 4 cm incision was made in the 7th intercostal space near the anterior axillary line, where a membrane incision expander was put in, and thoracoscopes and operating instruments operated through the port. Exploration revealed minor active bleeding in the parietal pleura around the fracture, after suction and electrocoagulation, hematoma and deformity were found in the 7th and 8th anterior rib, as well as 10th and 11th ribs, the bone friction sensation around the rib fracture line was evident when pressed. Special instruments were needed . The rib coaptation boards with 4 or 8 arms (manufactured by Lanzhou Seemine Shape Memory Alloy Co., Ltd, China) were used to fix the fractures. The implantation tool with detachable tong head (manufactured by Lanzhou Seemine Shape Memory Alloy Co., Ltd, China,) was used to connect the rib coaptation board and placed it to the broken ribs. An oval bending forcep (manufactured by Lanzhou Seemine Shape Memory Alloy Co., Ltd, China) was used to reduce displacements. After exposing fractures with an electrocoagulation hook burning, reduction was implement with forcep (for the 10th and 11th rib) or fingers (for the 7th and 8th rib). Loosened the arms of boards under 0℃ ice sterile saline, connected the boards and implantation tool, delivered boards to fractures, and inserted four embracing arms into the upper and lower edges of the fractured rib. After prayed 50℃ sterile saline, boards return to previous shape to clasp and fix the fractured rib. As the result, the rib fractures are stable without screws or wires . A drainage tube was placed from the incision, and the procedure end up with incision suturing layer by layer .\nPostoperatively, the patient was transferred to the ward for vital signs detection, oxygen inhalation, atomization, pain relief, hemostasis, and fluid therapy. On the post-operative day (POD) 1, he expressed his satisfaction at the apparent ease of the pain, and reexamination of chest CT showed that the fracture was well fixed . On the POD 2, since the fluid was only 50 ml, the drainage tube was removed, and the patient was discharged next day. A month later, the pain had entirely resolved. The follow-up examination showed the fracture healing well, and the patient returned to work.", + "fulltext_subclaims": [ + "A 53-year-old man accidentally fell off a three-meter high scaffolding while working.", + "He experienced severe chest pain and shortness of breath.", + "Upon arrival at the emergency department, oxygen saturation was 89% without oxygen inhalation.", + "Chest computed tomography showed left 7th through 11th rib fractures.", + "Chest computed tomography showed lower left lobe contusion.", + "Chest computed tomography showed hemothorax measured about 10% of the chest.", + "After treatment with oxygen, external fixation by band, and pain management, the symptoms were initially relieved.", + "The pain remained severe several hours later even after the use of pethidine.", + "He decided to undergo surgery.", + "The patient was placed in the right decubitus position.", + "A 4 cm incision was made in the 7th intercostal space near the anterior axillary line.", + "Thoracoscopes and operating instruments operated through the port.", + "Exploration revealed minor active bleeding in the parietal pleura around the fracture.", + "Hematoma and deformity were found in the 7th and 8th anterior rib.", + "Hematoma and deformity were found in the 10th and 11th ribs.", + "The bone friction sensation around the rib fracture line was evident when pressed.", + "The rib coaptation boards with 4 or 8 arms were used to fix the fractures.", + "The implantation tool with detachable tong head was used to connect the rib coaptation board and place it to the broken ribs.", + "An oval bending forcep was used to reduce displacements.", + "Reduction was implemented with forcep for the 10th and 11th rib.", + "Reduction was implemented with fingers for the 7th and 8th rib.", + "Loosened the arms of boards under 0℃ ice sterile saline.", + "Connected the boards and implantation tool.", + "Delivered boards to fractures.", + "Inserted four embracing arms into the upper and lower edges of the fractured rib.", + "After prayed 50℃ sterile saline, boards returned to previous shape to clasp and fix the fractured rib.", + "The rib fractures are stable without screws or wires.", + "A drainage tube was placed from the incision.", + "The procedure ended with incision suturing layer by layer.", + "On the post-operative day 1, chest CT showed that the fracture was well fixed.", + "On the post-operative day 2, the drainage tube was removed.", + "The patient was discharged the day after the drainage tube was removed.", + "A month later, the pain had entirely resolved.", + "The follow-up examination showed the fracture healing well.", + "The patient returned to work." + ], + "summary": "A 53-year-old man accidentally fell off a three-meter high scaffolding while working resulting in severe chest pain and shortness of breath. He was found with left 7th through 11th rib fractures with a pulmonary contusion from computed tomography (CT). A 4 cm incision was made in the 7th intercostal space in the midaxillary line, and complete uni-port VATS for SSRF were operated. The patient's pain was significantly relieved after the operation, and the scar was tiny and unapparent.", + "summary_subclaims": [ + "The patient is a 53-year-old man.", + "He accidentally fell off a three-meter high scaffolding.", + "He had severe chest pain.", + "He had shortness of breath.", + "Computed tomography showed left 7th through 11th rib fractures.", + "Computed tomography showed a pulmonary contusion.", + "A 4 cm incision was made in the 7th intercostal space in the midaxillary line.", + "Complete uni-port VATS for SSRF was performed.", + "The patient's pain was significantly relieved after the operation.", + "The scar was tiny and unapparent." + ] + }, + { + "id": "multiclinsum_test_2154_en.txt", + "fulltext": "In April 2018, a 37-year-old Syrian female came to the surgical outclinic of our institute in Aleppo-Syria, complaining of a palpable mass in her left breast, with retraction and ulceration of the skin, pain and redness. The mass grew gradually over the period of four months .\nThe patient is an illiterate housewife that lives in a rural area. She has one child that she has breastfed him.\nThe patient reported hypothyroidism. She was on l-thyroxin 50 μg/day but stopped the medicine two months ago without medical consultation. Otherwise, her past medical, surgical and medicinal history is clear, including pulmonary diseases.\nReview and examination of other systems was not significant. There was no history of weight loss, loss of appetite, night sweats or fever.\nThe patient performed an ultrasonography (US) a month earlier. It showed a (4 × 6) cm poorly identified structure, which infiltrates in the glandular tissue and distorted the normal structure of glandular lobes, but without observing an isolated mass. No dilation in the mammary ducts was observed. The US also revealed an enlarged left axillary lymph node, 2 cm in diameter. The right breast and the right axillary region showed no abnormalities. At that time, two biopsies from the mass were performed by an interventional radiologist to investigate the mass. Histopathologic examination revealed no malignancy with acute non-specific mastitis and foci of fat necrosis.\nWe performed another US and mammography for the two breasts. The mammography showed two dense and disproportionate breasts, and a (4 × 3.5) cm irregular mass located in the lateral upper quadrant of the left breast . For ultrasonography, the breasts were studied with a 7.5 MHz probe. We found a small, irregular, hypoechoic mass (4.5 × 3.6) cm located at 1 o’clock in the left breast, and an axillary lymph node in the left side was observed. We suspected malignancy.\nChest X-ray was normal.\nThe patient was admitted to our surgical department to be prepared for excisional biopsy of the mass.\nLaboratory values were as follows: Hb: 10.8 mg/dl– WBC: 10800/mm3 - TSH: 31.4 μIU/mL- CRP : 31 mg/L - ESR : 1st h 46.\nHypothyroidism was corrected before surgery by l-thyroxin.\nEchography of the thyroid gland was within normal limits with some degree of atrophy. Once the patient reached euthyroidism (TSH: 2.1 μIU/mL), we performed lumpectomy under general anesthesia .\nThe resected mass was tan and rubbery, measuring 13 cm. The cut section revealed irregular surface admixed with fat, and many dilated ducts with cystic formations and large areas of necrosis.\nMicroscopic examination revealed granulomatous caseating tuberculous mastitis in the left breast. .\nThen the patient was put on (Rifampicinb150 mg, Isoniazid 75 mg, Pyrazinamide 400 mg, Ethamputol 275 mg) and after one month of treatment by ATT drugs:\nHB: 14.5 mg/dl - WBC : 7500/mm3 -ESR : 34 1st hour - CRP : 6.8 mg/L - Iron : 70 mcg/dL.\nThe patient did not adhere to treatment because she lives in a remote village, with limited accessibility to TB treatment facilities due to war. She came after three months with 3 masses in her left breast, The patient was sent to a radiologist and the echography revealed the presence of three masses: the first mass was (2 × 1.5) cm above the middle of the surgical incision by (2) cm with irregular borders, the second was (2 × 0.6) cm with irregular borders below the end of the lateral line of surgical incision by (2) cm, and the third was (3) mm lateral to the latter described mass.\nNear the place of pervious surgical incision, there was a hypoechoic tissue (2 × 2) cm and the Doppler showed a relative increase in blood supply. The rest of glandular tissue looked normal. Three axillary lymph nodes were seen (17–13–12) mm with a normal adipose hilum.\nWe performed another lumpectomy. Biopsies were sent to the pathology laboratory and the result was caseating tuberculosis mastitis with abscess and fibrosis of left breast with no malignancy.\nThe patient was successfully treated after the excision of the three masses and returning to the ATT drugs (Rifampicin150 mg, Isoniazid 75 mg, Pyrazinamide 400 mg, Ethamputol 275 mg) for 9 months with thorough follow-up. Another echography was performed after a year and was normal and the patient recovered.", + "fulltext_subclaims": [ + "A 37-year-old Syrian female came to the surgical outclinic in April 2018.", + "She complained of a palpable mass in her left breast.", + "The mass had retraction and ulceration of the skin.", + "The mass grew gradually over four months.", + "The patient is an illiterate housewife.", + "She lives in a rural area.", + "She has one child that she has breastfed.", + "The patient reported hypothyroidism.", + "She was on l-thyroxin 50 μg/day.", + "She stopped the medicine two months ago without medical consultation.", + "Her past medical, surgical, and medicinal history is clear, including pulmonary diseases.", + "There was no history of weight loss, loss of appetite, night sweats, or fever.", + "An ultrasonography a month earlier showed a 4 × 6 cm poorly identified structure.", + "The structure infiltrated the glandular tissue and distorted the normal structure of glandular lobes.", + "No isolated mass was observed.", + "No dilation in the mammary ducts was observed.", + "An enlarged left axillary lymph node, 2 cm in diameter, was observed.", + "The right breast and right axillary region showed no abnormalities.", + "Two biopsies from the mass were performed by an interventional radiologist.", + "Histopathologic examination revealed no malignancy.", + "Histopathologic examination showed acute non-specific mastitis.", + "Histopathologic examination showed foci of fat necrosis.", + "Mammography showed two dense and disproportionate breasts.", + "Mammography showed a 4 × 3.5 cm irregular mass in the lateral upper quadrant of the left breast.", + "Ultrasonography found a 4.5 × 3.6 cm irregular, hypoechoic mass in the left breast.", + "An axillary lymph node in the left side was observed.", + "Malignancy was suspected.", + "Chest X-ray was normal.", + "The patient was admitted for excisional biopsy of the mass.", + "Hb was 10.8 mg/dl.", + "WBC was 10800/mm3.", + "TSH was 31.4 μIU/mL.", + "CRP was 31 mg/L.", + "ESR was 46.", + "Hypothyroidism was corrected before surgery by l-thyroxin.", + "Echography of the thyroid gland showed some degree of atrophy.", + "Once the patient reached euthyroidism (TSH: 2.1 μIU/mL), lumpectomy was performed under general anesthesia.", + "The resected mass was tan and rubbery, measuring 13 cm.", + "The cut section revealed irregular surface admixed with fat.", + "The cut section showed many dilated ducts with cystic formations.", + "The cut section showed large areas of necrosis.", + "Microscopic examination revealed granulomatous caseating tuberculous mastitis in the left breast.", + "The patient was put on Rifampicin 150 mg, Isoniazid 75 mg, Pyrazinamide 400 mg, and Ethamputol 275 mg.", + "After one month of treatment, HB was 14.5 mg/dl.", + "After one month of treatment, WBC was 7500/mm3.", + "After one month of treatment, ESR was 34.", + "After one month of treatment, CRP was 6.8 mg/L.", + "After one month of treatment, Iron was 70 mcg/dL.", + "The patient did not adhere to treatment.", + "She lives in a remote village.", + "Accessibility to TB treatment facilities was limited due to war.", + "After three months, she had three masses in her left breast.", + "Echography revealed three masses.", + "The first mass was 2 × 1.5 cm above the middle of the surgical incision.", + "The first mass had irregular borders.", + "The second mass was 2 × 0.6 cm below the end of the lateral line of the surgical incision.", + "The second mass had irregular borders.", + "The third mass was 3 mm lateral to the second mass.", + "Near the previous surgical incision, there was a 2 × 2 cm hypoechoic tissue.", + "Doppler showed a relative increase in blood supply.", + "Three axillary lymph nodes were seen (17–13–12 mm) with a normal adipose hilum.", + "Another lumpectomy was performed.", + "Biopsies were sent to the pathology laboratory.", + "The result was caseating tuberculosis mastitis with abscess and fibrosis of the left breast.", + "The result showed no malignancy.", + "The patient was successfully treated after excision of the three masses.", + "She returned to ATT drugs for 9 months.", + "She had thorough follow-up.", + "Another echography was performed after a year and was normal.", + "The patient recovered." + ], + "summary": "We report a case of a 37-year-old female who admitted to the surgical clinic with a 4-month history of gradually growing mass in the breast. On physical examination there were a palpable mass, painful superficial abscess in her left lateral upper quarter of breast, redness and nipple retraction and ulceration. The patient history and physical examination were clear except for uncontrolled hypothyroidism. Radiological tests including mammography, echography and laboratory investigations were performed. The patient underwent lumpectomy. Histopathologic examination showed caseating Tuberculous Mastitis and a large tuberculous abscess, with no malignancy. Patient was put on anti-tubercular chemotherapy, but recurred after three months with three masses in the same area because she did not adhere to the treatment. Lumpectomy and Anti-tuberculous therapy were repeated again with close follow-up, and the patient recovered.", + "summary_subclaims": [ + "The patient is a 37-year-old female.", + "She had a 4-month history of a gradually growing mass in the breast.", + "On physical examination, there was a palpable mass.", + "There was a painful superficial abscess in her left lateral upper quarter of breast.", + "There was redness.", + "There was nipple retraction.", + "There was ulceration.", + "The patient history and physical examination were clear except for uncontrolled hypothyroidism.", + "Radiological tests including mammography, echography, and laboratory investigations were performed.", + "The patient underwent lumpectomy.", + "Histopathologic examination showed caseating Tuberculous Mastitis.", + "Histopathologic examination showed a large tuberculous abscess.", + "Histopathologic examination showed no malignancy.", + "The patient was put on anti-tubercular chemotherapy.", + "The patient had a recurrence after three months with three masses in the same area.", + "The recurrence occurred because she did not adhere to the treatment.", + "Lumpectomy and Anti-tuberculous therapy were repeated again.", + "The patient recovered." + ] + }, + { + "id": "multiclinsum_test_791_en.txt", + "fulltext": "We report the case of a 66-year-old female patient suffering from acute heart failure due to severe aortic and mitral stenosis. She underwent a combined mitral and aortic valve replacement with bioprosthetic valves (respectively 29-mm Epic St Jude Medical and 21-mm Trifecta GT St Jude Medical) on October 7th, 2021 and was discharged after a 10-day hospitalization.\n4 weeks later, she was admitted to hospital for asthenia and fever. A paroxystic third-degree atrioventricular block was diagnosed on the electrocardiogram and blood cultures were positive to Enterococcus faecalis. Transthoracic echocardiography (TTE) confirmed the presence of a double supracentimetric endocarditis on the two prosthetic valves with an aortic root abscess. CT-scan did not find any sign of septic embolism. She received an antibiotherapy with Ceftriaxone and Amoxicillin.\nThe patient underwent a replacement of the aortic and mitral prosthetic valves and the implantation of a leadless pacemaker on November, 07th 2021.\nSurgical examination confirmed the diagnosis of large vegetations of the two prosthetic valves and a massive destruction of the mitral annulus. The two prosthetic valves were replaced. A 21-mm Edwards Magna Ease valve was placed in aortic position. Nevertheless, because of the extensive deterioration of the mitral annulus, the 31-mm Edwards Magna Ease valve was inserted in supra-annular mitral position. Immediate post-operative transoesophageal echocardiography (TOE) was satisfying, with a good function of the new prosthetic valves. She was weaned from mechanical ventilation the next day.\nThe postoperative course was marked by an acute kidney injury needing continuous renal replacement therapy. One week after the surgery, she developed a severe hypoxemic respiratory failure due to a pulmonary oedema needing mechanical ventilation.\nThe TOE revealed a LA wall dissection and the creation of a new atrium cavity interpreted as a FA behind the LA posterior wall, squeezing the left atrium at every systole . The two new prosthetic valves were functional and unscathed without intra- nor para-valvular regurgitation. A severe left-ventricular regurgitant jet filled the FA pushing the LA posterior wall through the LA, probably causing pulmonary veins obstruction . No shunts were detected by the bubble test and the aortic wall and the interatrial septum were normal.\nContrast-enhanced synchronized cardiac CT-scan (128-slice) was realized to perform a 3D reconstruction imaging to guide a potential surgery. It confirmed a FA measuring 65 × 40 x 30 mm behind the LA with a mass effect on it, communicating with the left ventricle outflow tract through a 23-mm defect, close to the mitral prosthetic valve . Pulmonary veins were correctly inserted in the right atrium.\nUnfortunately, weaning from mechanical ventilation was unsuccessful. Considering the high risk of a third surgery, the impossibility of a percutaneous treatment facing a very large collar and false aneurysm and the worsening of the clinical course, a palliative care support was collegially decided and the patient finally died.", + "fulltext_subclaims": [ + "The patient was a 66-year-old female.", + "She suffered from acute heart failure due to severe aortic and mitral stenosis.", + "She underwent a combined mitral and aortic valve replacement with bioprosthetic valves on October 7th, 2021.", + "The mitral valve was replaced with a 29-mm Epic St Jude Medical valve.", + "The aortic valve was replaced with a 21-mm Trifecta GT St Jude Medical valve.", + "She was discharged after a 10-day hospitalization.", + "Four weeks later, she was admitted to hospital for asthenia and fever.", + "A paroxystic third-degree atrioventricular block was diagnosed on the electrocardiogram.", + "Blood cultures were positive to Enterococcus faecalis.", + "Transthoracic echocardiography confirmed the presence of a double supracentimetric endocarditis on the two prosthetic valves.", + "A CT-scan did not find any sign of septic embolism.", + "She received an antibiotherapy with Ceftriaxone and Amoxicillin.", + "The patient underwent a replacement of the aortic and mitral prosthetic valves on November 07th, 2021.", + "A leadless pacemaker was implanted on November 07th, 2021.", + "Surgical examination confirmed the diagnosis of large vegetations of the two prosthetic valves.", + "There was a massive destruction of the mitral annulus.", + "The two prosthetic valves were replaced.", + "A 21-mm Edwards Magna Ease valve was placed in aortic position.", + "A 31-mm Edwards Magna Ease valve was inserted in supra-annular mitral position.", + "Immediate post-operative transoesophageal echocardiography was satisfying, with a good function of the new prosthetic valves.", + "She was weaned from mechanical ventilation the next day.", + "The postoperative course was marked by an acute kidney injury needing continuous renal replacement therapy.", + "One week after the surgery, she developed a severe hypoxemic respiratory failure due to a pulmonary oedema needing mechanical ventilation.", + "The TOE revealed a LA wall dissection and the creation of a new atrium cavity interpreted as a FA behind the LA posterior wall.", + "The two new prosthetic valves were functional and unscathed without intra- nor para-valvular regurgitation.", + "A severe left-ventricular regurgitant jet filled the FA pushing the LA posterior wall through the LA.", + "Contrast-enhanced synchronized cardiac CT-scan was realized to perform a 3D reconstruction imaging.", + "The CT-scan confirmed a FA measuring 65 × 40 x 30 mm behind the LA.", + "The FA communicated with the left ventricle outflow tract through a 23-mm defect.", + "Weaning from mechanical ventilation was unsuccessful.", + "A palliative care support was collegially decided.", + "The patient finally died." + ], + "summary": "We report the case of a 66-year-old female patient who underwent a combined mitral and aortic valve replacement for degenerative valvular disease. She presented an infectious endocarditis revealed by a third-degree atrioventricular bloc and had a redo mitral- and aortic valve replacement. Mitral valve was inserted in supra-annular position due to annular destruction. Post-operative course was marked by a refractory acute heart failure explained by a left atrial wall dissection confirmed by transoesophageal echocardiography and synchronized cardiac CT-scan. Surgical treatment was theoretically indicated but considering the high risk of a third surgery, a palliative care support was collegially decided.", + "summary_subclaims": [ + "The patient was a 66-year-old female.", + "She underwent a combined mitral and aortic valve replacement.", + "The indication was degenerative valvular disease.", + "She presented an infectious endocarditis revealed by a third-degree atrioventricular bloc.", + "She had a redo mitral- and aortic valve replacement.", + "The mitral valve was inserted in a supra-annular position due to annular destruction.", + "The post-operative course was marked by refractory acute heart failure.", + "The cause of the heart failure was a left atrial wall dissection confirmed by transoesophageal echocardiography.", + "The dissection was also confirmed by a synchronized cardiac CT-scan.", + "Surgical treatment was theoretically indicated.", + "A third surgery was considered to be high risk.", + "A palliative care support was collegially decided." + ] + }, + { + "id": "multiclinsum_test_1222_en.txt", + "fulltext": "A 52-year-old, right-handed, previously healthy woman presented to our hospital for unprovoked numbness and worsening impairment of sensibility at the level of her right thumb, index, middle finger, and radial half of her ring finger. She also complained of impairment in everyday activities due to worsening weakness of her opponens pollicis muscle. Only slight improvement in her symptoms was reported during the past 12 months despite splinting the hand using a wrist brace, undergoing physiotherapy, and taking high doses of non-steroidal anti-inflammatory drugs (NSAIDs) and Gabapentin. The patient reported a chronic history of repetitive movements of the fingers and wrists with chronic pressure points on the right wrist.\nOn examination, the affected hand revealed no swelling or local heat. Atrophy of the thenar muscle and hypoesthesia in the distribution of the median nerve were noted. Both Phalen’s test and Tinel’s sign were positive on the right side with no restriction in the range of motion of wrist and fingers. Nerve electrodiagnostic testing suggested right median nerve compression at the level of the right carpal tunnel. An initial plain radiograph of the right wrist showed an oval radio-opacity on the volar side of the wrist joint facing the carpal bones .\nA confirmatory magnetic resonance imaging (MRI) of the right hand and wrist showed a solitary oval calcification (low-intensity lesion both in T1WI and T2WI) measuring 2 × 0.8 × 0.6 cm (cm), located in the carpal tunnel centrally between the flexor tendons of the wrist, at the lunatum-capitatum junction, without surrounding adherence (the boundary between the lesion and the surrounding tissues was clear) . The lesion is also surrounded by a reactive fluid collection . The MRI also showed subtle tenosynovitis of the flexor’s tendon sheaths, with mild compression of the median nerve . The patient’s full blood count, vitamin D, calcium, phosphate, electrolytes, uric acid, urea, creatinine, and alkaline phosphatase were within normal range. Other laboratory data including an endocrine and rheumatology panel were also normal. Subsequently, the patient was diagnosed with CTS secondary to a localized calcareous mass.\nGiven that conservative treatment was ineffective, the patient’s condition was managed by open incisional carpal tunnel release. An incision of approximately 4 cm was performed on the volar side of the right wrist facing the third metacarpal bone . The palmar aponeurosis was then dissected, and the flexor retinaculum was located and transected. The white calcareous tumor was lying over the carpal bones of the osteofibrous canal, and it was only visualized after retracting the median nerve. A 2.1 by 1.0 cm mass was easily removed with no adhesion to surrounding tissues. Histological sections showed calcified deposits encased in a fibrocartilaginous tissue with inflammatory infiltrates composed of giant cell granulomas. These findings supported the diagnosis of tumoral calcinosis [, ].\nDuring her follow up, three months following the surgery, no clinical or radio-graphical signs of recurrence were noted and the patient reported complete resolution of her symptoms.", + "fulltext_subclaims": [ + "The patient is a 52-year-old, right-handed, previously healthy woman.", + "She presented with unprovoked numbness and worsening impairment of sensibility at the level of her right thumb, index, middle finger, and radial half of her ring finger.", + "She also complained of impairment in everyday activities due to worsening weakness of her opponens pollicis muscle.", + "Only slight improvement in her symptoms was reported during the past 12 months despite splinting the hand using a wrist brace, undergoing physiotherapy, and taking high doses of non-steroidal anti-inflammatory drugs (NSAIDs) and Gabapentin.", + "The patient reported a chronic history of repetitive movements of the fingers and wrists with chronic pressure points on the right wrist.", + "On examination, the affected hand revealed no swelling or local heat.", + "Atrophy of the thenar muscle and hypoesthesia in the distribution of the median nerve were noted.", + "Both Phalen’s test and Tinel’s sign were positive on the right side.", + "Nerve electrodiagnostic testing suggested right median nerve compression at the level of the right carpal tunnel.", + "An initial plain radiograph of the right wrist showed an oval radio-opacity on the volar side of the wrist joint facing the carpal bones.", + "A confirmatory magnetic resonance imaging (MRI) of the right hand and wrist showed a solitary oval calcification measuring 2 × 0.8 × 0.6 cm.", + "The lesion was located in the carpal tunnel centrally between the flexor tendons of the wrist, at the lunatum-capitatum junction.", + "The boundary between the lesion and the surrounding tissues was clear.", + "The lesion was surrounded by a reactive fluid collection.", + "The MRI also showed subtle tenosynovitis of the flexor’s tendon sheaths.", + "The MRI showed mild compression of the median nerve.", + "The patient’s full blood count, vitamin D, calcium, phosphate, electrolytes, uric acid, urea, creatinine, and alkaline phosphatase were within normal range.", + "Other laboratory data including an endocrine and rheumatology panel were also normal.", + "The patient was diagnosed with CTS secondary to a localized calcareous mass.", + "The patient’s condition was managed by open incisional carpal tunnel release.", + "An incision of approximately 4 cm was performed on the volar side of the right wrist facing the third metacarpal bone.", + "The palmar aponeurosis was then dissected, and the flexor retinaculum was located and transected.", + "A 2.1 by 1.0 cm mass was easily removed with no adhesion to surrounding tissues.", + "Histological sections showed calcified deposits encased in a fibrocartilaginous tissue with inflammatory infiltrates composed of giant cell granulomas.", + "These findings supported the diagnosis of tumoral calcinosis.", + "Three months following the surgery, no clinical or radiographical signs of recurrence were noted.", + "The patient reported complete resolution of her symptoms." + ], + "summary": "A 52-year-old woman presented for a one-year history of numbness and paresthesia in her right hand. The patient's signs, symptoms, physical examination, and nerve electrodiagnostic testing suggested median nerve compression at the level of the carpal tunnel. However, a confirmatory magnetic resonance imaging of the wrist showed a localized calcareous lesion in the carpal tunnel. Subsequently, carpal tunnel release and mass excision were successfully performed with no recurrence at a 3-month interval.", + "summary_subclaims": [ + "The patient is a 52-year-old woman.", + "The patient had a one-year history of numbness and paresthesia in her right hand.", + "The patient's signs, symptoms, physical examination, and nerve electrodiagnostic testing suggested median nerve compression at the level of the carpal tunnel.", + "A confirmatory magnetic resonance imaging of the wrist showed a localized calcareous lesion in the carpal tunnel.", + "Carpal tunnel release and mass excision were successfully performed.", + "There was no recurrence at a 3-month interval." + ] + }, + { + "id": "multiclinsum_test_139_en.txt", + "fulltext": "A 70-year-old man visited our emergency unit with chief complaints of epigastric pain and vomitus niger 2 h after the onset of symptoms. After consultation in our hospital, the patient had black vomit. His blood pressure was 168/109 mmHg, pulse was 73 bpm, and body temperature 36.7 °C. For abdominal findings, he had rebound tenderness, although tenderness was present in the epigastrium. With regard to significant medical history, he had Mallory–Weiss syndrome, high blood pressure, and hyperlipidemia detected 14 years ago, as well as removal of Helicobacter pylori 2 years prior. For relevant lifestyle history, the patient claims to drink five cups of coffee, consumes 360 cc of alcohol each day, and is currently a non-smoker (quit smoking 10 years ago). He is currently medicated with oral antihypertensive agents. Results of his blood tests revealed white blood cell count of 13,560/ml and C-reactive protein of 0.3 mg/dl.\nContrast computed tomography (CT) revealed empyema and fluid retention in the mediastinum . There were no abnormal findings such as fluid retention and pneumothorax in the thoracic cavity. Upper GI series (with Urografin) detected leakage of contrast media into the mediastinum from the lower intrathoracic esophagus on the left side . We repeated plain CT scans following the upper GI series and confirmed leakage of contrast media into the mediastinum from the site just above the cardia to the tracheal bifurcation. Based on the above findings, the patient was diagnosed with spontaneous esophageal rupture and we decided to perform emergency surgery. Because the location of the perforation was suspected to be the left side of the lower esophagus, the patient’s vital sign was stable, and the area of perforation was localized to the mediastinum, laparoscopic transhiatal simple closure was chosen. We performed the procedure 11 h after the onset of symptoms.\nThe ports were inserted using the 5-hole approach. No abnormal findings were found in the abdominal cavity. It was found that contamination was mainly on the left side, and we initially searched for perforation placement from the left side of the esophagus. We removed a volume of tissue equivalent to three quarters of the circumference of the esophagus from the dorsal esophagus to the right dorsal esophagus. A perforation of 2 cm in diameter was observed at the site of the rostral portion at approximately 4 cm from the esophageal hiatus . No intrathoracic perforation was observed. Endoscopy of the upper gastrointestinal tract was performed during surgery, and from the esophageal lumen, it was confirmed that this was the site of perforation. The perforation was closed with three stitches using 3–0 absorbable sutures . Before concluding surgery, the mediastinum was irrigated with saline and two drains were inserted into the subdiaphragm around hiatal space transperitoneally. The total operative time was 178 min, and the total volume of bleeding was 2 ml.\nAfter surgery, the two drains were used for intermittent suction, and we continued treatment with proton pump inhibitor (30 mg, 2 times a day) and antibiotics (MEPM 1 g, 3 times a day). The patient started ambulation on the first postoperative day. His white cell count was normalized on postoperative day 4. The gastric tube was removed with fluoroscopic guidance. Antibiotics were discontinued on postoperative day 6. Oral intake of food was initiated on postoperative day 7, and after shifting meals to a solid diet, recovery was uneventful. The patient was discharged on postoperative day 15 and continued proton pump inhibitor therapy as an outpatient. Healing cicatrization was found at the site of rupture by endoscopy of the upper gastrointestinal tract . The patient was advised to improve his lifestyle. He showed no signs of recurrence two or more years after surgery.", + "fulltext_subclaims": [ + "A 70-year-old man visited our emergency unit with chief complaints of epigastric pain and vomitus niger 2 h after the onset of symptoms.", + "After consultation in our hospital, the patient had black vomit.", + "His blood pressure was 168/109 mmHg.", + "His pulse was 73 bpm.", + "His body temperature was 36.7 °C.", + "He had rebound tenderness.", + "Tenderness was present in the epigastrium.", + "He had Mallory–Weiss syndrome.", + "He had high blood pressure.", + "He had hyperlipidemia detected 14 years ago.", + "He had removal of Helicobacter pylori 2 years prior.", + "He consumes 360 cc of alcohol each day.", + "He is a non-smoker who quit smoking 10 years ago.", + "He is currently medicated with oral antihypertensive agents.", + "Results of his blood tests revealed white blood cell count of 13,560/ml.", + "Contrast computed tomography (CT) revealed empyema and fluid retention in the mediastinum.", + "There were no abnormal findings such as fluid retention and pneumothorax in the thoracic cavity.", + "Upper GI series detected leakage of contrast media into the mediastinum from the lower intrathoracic esophagus on the left side.", + "We repeated plain CT scans following the upper GI series and confirmed leakage of contrast media into the mediastinum from the site just above the cardia to the tracheal bifurcation.", + "The patient was diagnosed with spontaneous esophageal rupture.", + "We decided to perform emergency surgery.", + "Laparoscopic transhiatal simple closure was chosen.", + "The procedure was performed 11 h after the onset of symptoms.", + "The ports were inserted using the 5-hole approach.", + "No abnormal findings were found in the abdominal cavity.", + "Contamination was mainly on the left side.", + "We initially searched for perforation placement from the left side of the esophagus.", + "A perforation of 2 cm in diameter was observed at the site of the rostral portion at approximately 4 cm from the esophageal hiatus.", + "No intrathoracic perforation was observed.", + "Endoscopy of the upper gastrointestinal tract was performed during surgery.", + "The perforation was closed with three stitches using 3–0 absorbable sutures.", + "The total operative time was 178 min.", + "The total volume of bleeding was 2 ml.", + "After surgery, the two drains were used for intermittent suction.", + "We continued treatment with proton pump inhibitor (30 mg, 2 times a day) and antibiotics (MEPM 1 g, 3 times a day).", + "The patient started ambulation on the first postoperative day.", + "His white cell count was normalized on postoperative day 4.", + "The gastric tube was removed with fluoroscopic guidance.", + "Antibiotics were discontinued on postoperative day 6.", + "Oral intake of food was initiated on postoperative day 7.", + "The patient was discharged on postoperative day 15.", + "He continued proton pump inhibitor therapy as an outpatient.", + "Healing cicatrization was found at the site of rupture by endoscopy of the upper gastrointestinal tract.", + "The patient showed no signs of recurrence two or more years after surgery." + ], + "summary": "A 70-year-old man visited our hospital with chief complaints of epigastric pain and vomitus niger. He was diagnosed with spontaneous esophageal rupture in the left wall of the lower esophagus by computed tomography and upper gastrointestinal (GI) series. At 11 h after the onset of symptoms, we performed laparoscopic transhiatal suture closure and lavage drainage. We performed transhiatal esophageal replacement using the 5-hole approach. We observed a perforation of 2 cm in diameter at the site of the rostral portion approximately 4 cm from the esophageal hiatus. All layers were closed with three stitches using 3-0 absorbable sutures. No perforation was observed in the thoracic cavity. The total operative time was 178 min, and total bleeding was 2 ml. He had no postoperative complications and was discharged on day 15 after the procedure. He received continuous proton pump inhibitor therapy as an outpatient. Healing cicatrization was found at the site of rupture by esophagogastroscopy. The patient was advised to improve his lifestyle and has shown no signs of recurrence over 2 years from the date of surgery.", + "summary_subclaims": [ + "The patient was a 70-year-old man.", + "The patient had epigastric pain.", + "The patient had vomitus niger.", + "The patient was diagnosed with spontaneous esophageal rupture in the left wall of the lower esophagus.", + "Computed tomography was used to diagnose the esophageal rupture.", + "An upper gastrointestinal series was used to diagnose the esophageal rupture.", + "Laparoscopic transhiatal suture closure was performed.", + "Lavage drainage was performed.", + "Transhiatal esophageal replacement was performed using the 5-hole approach.", + "A perforation of 2 cm in diameter was observed.", + "The perforation was located at the rostral portion approximately 4 cm from the esophageal hiatus.", + "All layers were closed with three stitches using 3-0 absorbable sutures.", + "No perforation was observed in the thoracic cavity.", + "The total operative time was 178 min.", + "The total bleeding was 2 ml.", + "The patient had no postoperative complications.", + "The patient was discharged on day 15 after the procedure.", + "The patient received continuous proton pump inhibitor therapy as an outpatient.", + "Healing cicatrization was found at the site of rupture by esophagogastroscopy.", + "The patient was advised to improve his lifestyle.", + "The patient has shown no signs of recurrence over 2 years from the date of surgery." + ] + }, + { + "id": "multiclinsum_test_3232_en.txt", + "fulltext": "The patient was a woman in her 80s who had previously been diagnosed with primary biliary cirrhosis and decompensated cirrhosis, classified as class B (Child–Pugh score was 9). At her outpatient visit, which was 23 days prior to her surgery, her serum potassium levels were 6.1 mEq/L; however, there was no evidence of abnormalities on her electrocardiogram. She was prescribed SZC at an initial dosage of 10 g three times a day for 3 days, followed by 5 g three times a day for 25 days to treat her hyperkalemia. Telmisartan 20 mg tablet was discontinued. The patient began to take SZC as instructed after receiving the medication on the same day. The concomitant medications she was receiving were: vonoprazan 10 mg, azosemide 30 mg, tolvaptan 7.5 mg, ursodeoxycholic acid 300 mg, polaprezinc 75 mg, LIVACT granules (L-isoleucine, L-leucine, and L-valine granules), and Aminoleban EN powder. However, we could not pay attention to the safety management regarding the changes in potassium levels associated with the consumption of SZC.\n\nThe ammonia level of the patient was 24 µg/dL, which was within the normal range, approximately 1 year before admission. Furthermore, there were no problems with communication during subsequent outpatient visits, because of which the ammonia level was not measured. At the time of admission, her ammonia level was 37 µg/dL. During the course of hospitalization, her ammonia levels were measured several times and ranged between 31 and 45 µg/dL, with no evidence of abnormalities. She had been taking her medication as prescribed until her hospitalization. The patient was assisted by family members and regularly took the SZC for approximately 23 days.\n\nThe day before surgery, after having dinner at around 7 to 8 p.m., the patient experienced abdominal pain and nausea at around 10:30 p.m., and she had to be rushed to our hospital. A computed tomography (CT) scan was performed, and an axial view of the scan revealed free intraperitoneal gas and ascites in the upper abdominal space. A high-intensity fecal mass was identified inside the colon and outside the intestinal tract at the pelvic level. Subsequent laboratory analysis identified several irregularities, including a potassium level of 1.9 mEq/L, blood urea nitrogen level of 27.5 mg/dL, creatinine of 1.22 mg/dL, hemoglobin level of 8.8 g/dL, and white blood cell count of 8100/µL. However, the C-reactive protein level was 0.20 mg/dL. The estimated glomerular filtration rate was 32.0 mL/min/1.73m2. Emergency surgery was performed the day following her admission (defined as Day 0). Several serous ascites and free intraperitoneal gas were observed in the epigastrium due to cirrhosis. Ascites-like watery stools were observed from the left lower abdominal quadrant to the pouch of Douglas, and hard stools were observed outside the intestinal tract in the lower abdominal quadrant. Hartmann’s operation with drainage was performed for repairing the sigmoid colon perforation. The postoperative X-ray images revealed accumulation of SZC in the feces. The perforation size of the resected specimen was 13.0 mm × 7.0 mm, and macroscopic findings did not reveal necrosis or bleeding. Microscopic findings did not reveal significant inflammatory cell infiltration, ischemic changes, or neoplasia around the perforation. The patient continued to receive critical care services in the intensive care unit (ICU) after surgery.\n\nContinuous hemodiafiltration was initiated on Day 0 due to a diagnosis of acute kidney injury (AKI), which was changed to hemodialysis (HD) on Day 7. SZC was discontinued after admission, and potassium was administered intravenously as needed. Despite the administration of multiple gastroprokinetic agents and laxatives, it took about 1 week for the hard stools containing residual SZC to be excreted. The X-ray images indicated the excretion of the residual SZC. Enteral nutrition was resumed on Day 7, and swallowing training was initiated on Day 8 following the patient’s transfer from the ICU to the medical ward. On Day 13, she developed a lacunar infarction and was treated conservatively. Her renal function improved, and HD was discontinued on Day 36. Then, on Day 51, she developed sudden circulatory failure. Cardiac catheterization revealed acute myocardial infarction caused by the obstruction of the right coronary artery. Thrombectomy and transcatheter stent placement were performed. The patient was also diagnosed with advanced rectal cancer during the hospital stay. Curative operation and stoma closure were considered inoperable because of her physical condition.\n\nOn the 95th day following surgery, despite an improvement in her condition, it was determined that a discharge to home would be difficult; hence, the patient was transferred to another hospital for rehabilitation.", + "fulltext_subclaims": [ + "The patient was a woman in her 80s.", + "She had previously been diagnosed with primary biliary cirrhosis.", + "She had decompensated cirrhosis classified as class B.", + "Her Child–Pugh score was 9.", + "At her outpatient visit 23 days prior to surgery, her serum potassium levels were 6.1 mEq/L.", + "There was no evidence of abnormalities on her electrocardiogram.", + "She was prescribed SZC at an initial dosage of 10 g three times a day for 3 days.", + "She was prescribed SZC at 5 g three times a day for 25 days.", + "Telmisartan 20 mg tablet was discontinued.", + "The patient began to take SZC as instructed after receiving the medication on the same day.", + "The concomitant medications she was receiving included vonoprazan 10 mg.", + "The concomitant medications she was receiving included azosemide 30 mg.", + "The concomitant medications she was receiving included tolvaptan 7.5 mg.", + "The concomitant medications she was receiving included ursodeoxycholic acid 300 mg.", + "The concomitant medications she was receiving included polaprezinc 75 mg.", + "The concomitant medications she were receiving included LIVACT granules.", + "The concomitant medications she were receiving included Aminoleban EN powder.", + "We could not pay attention to the safety management regarding the changes in potassium levels associated with the consumption of SZC.", + "The ammonia level of the patient was 24 µg/dL approximately 1 year before admission.", + "There were no problems with communication during subsequent outpatient visits.", + "The ammonia level was not measured during subsequent outpatient visits.", + "At the time of admission, her ammonia level was 37 µg/dL.", + "During the course of hospitalization, her ammonia levels ranged between 31 and 45 µg/dL.", + "There were no evidence of abnormalities in her ammonia levels during hospitalization.", + "She had been taking her medication as prescribed until her hospitalization.", + "The patient was assisted by family members.", + "She regularly took the SZC for approximately 23 days.", + "The day before surgery, after having dinner at around 7 to 8 p.m., the patient experienced abdominal pain and nausea at around 10:30 p.m.", + "A computed tomography (CT) scan was performed.", + "An axial view of the CT scan revealed free intraperitoneal gas.", + "An axial view of the CT scan revealed ascites in the upper abdominal space.", + "A high-intensity fecal mass was identified inside the colon.", + "A high-intensity fecal mass was identified outside the intestinal tract at the pelvic level.", + "Subsequent laboratory analysis identified a potassium level of 1.9 mEq/L.", + "Subsequent laboratory analysis identified a blood urea nitrogen level of 27.5 mg/dL.", + "Subsequent laboratory analysis identified a creatinine level of 1.22 mg/dL.", + "Subsequent laboratory analysis identified a hemoglobin level of 8.8 g/dL.", + "Subsequent laboratory analysis identified a white blood cell count of 8100/µL.", + "The C-reactive protein level was 0.20 mg/dL.", + "The estimated glomerular filtration rate was 32.0 mL/min/1.73m2.", + "Emergency surgery was performed the day following her admission.", + "Several serous ascites and free intraperitoneal gas were observed in the epigastrium due to cirrhosis.", + "Ascites-like watery stools were observed from the left lower abdominal quadrant to the pouch of Douglas.", + "Hard stools were observed outside the intestinal tract in the lower abdominal quadrant.", + "Hartmann’s operation with drainage was performed for repairing the sigmoid colon perforation.", + "The postoperative X-ray images revealed accumulation of SZC in the feces.", + "The perforation size of the resected specimen was 13.0 mm × 7.0 mm.", + "Macroscopic findings did not reveal necrosis or bleeding.", + "Microscopic findings did not reveal significant inflammatory cell infiltration.", + "Microscopic findings did not reveal ischemic changes.", + "Microscopic findings did not reveal neoplasia around the perforation.", + "The patient continued to receive critical care services in the ICU after surgery.", + "Continuous hemodiafiltration was initiated on Day 0 due to a diagnosis of acute kidney injury.", + "Continuous hemodiafiltration was changed to hemodialysis on Day 7.", + "SZC was discontinued after admission.", + "Potassium was administered intravenously as needed.", + "It took about 1 week for the hard stools containing residual SZC to be excreted.", + "X-ray images indicated the excretion of the residual SZC.", + "Enteral nutrition was resumed on Day 7.", + "Swallowing training was initiated on Day 8 following the patient’s transfer from the ICU to the medical ward.", + "On Day 13, she developed a lacunar infarction.", + "She was treated conservatively for the lacunar infarction.", + "Her renal function improved.", + "Hemodialysis was discontinued on Day 36.", + "On Day 51, she developed sudden circulatory failure.", + "Cardiac catheterization revealed acute myocardial infarction caused by the obstruction of the right coronary artery.", + "Thrombectomy and transcatheter stent placement were performed.", + "The patient was also diagnosed with advanced rectal cancer during the hospital stay.", + "Curative operation and stoma closure were considered inoperable because of her physical condition.", + "On the 95th day following surgery, the patient was transferred to another hospital for rehabilitation." + ], + "summary": "A woman in her 80s with a history of primary biliary cirrhosis and decompensated cirrhosis accompanied by hyperkalemia was administered SZC. The patient was rushed to the hospital on the 23rd day following the commencement of SZC, complaining of abdominal pain and nausea. She suffered from sigmoid colon perforation. Hartmann's operation with drainage was performed. SZC was discontinued after admission, following which the serum potassium levels normalized. Despite the diagnosis of advanced rectal cancer during her hospital stay, the curative operation and stoma closure were judged to be inoperable because of her physical condition.", + "summary_subclaims": [ + "The patient was a woman in her 80s.", + "She had a history of primary biliary cirrhosis.", + "She had decompensated cirrhosis.", + "She had hyperkalemia.", + "She was administered SZC.", + "She was rushed to the hospital on the 23rd day following the commencement of SZC.", + "She complained of abdominal pain.", + "She complained of nausea.", + "She suffered from sigmoid colon perforation.", + "Hartmann's operation with drainage was performed.", + "SZC was discontinued after admission.", + "Serum potassium levels normalized following discontinuation of SZC.", + "She was diagnosed with advanced rectal cancer during her hospital stay.", + "Curative operation was judged to be inoperable because of her physical condition.", + "Stoma closure was judged to be inoperable because of her physical condition." + ] + }, + { + "id": "multiclinsum_test_2494_en.txt", + "fulltext": "Patient is a 56-year-old female with body mass index of 22.5 kg/m2 and previous clinical history of diffuse scleroderma, intestinal pneumonitis, mild pulmonary hypertension, secondary gastroesophageal reflux, and severe esophageal motility disease. Receiving immunosuppression, antihypertensive, proton pump inhibitor and prokinetic management with weak response, patient is admitted for surgical management after a 1-year follow-up with cardiology, pneumology, and gastroenterology.\nAt admission, patient was symptomatic with a previous diagnosis of esophageal aperistalsis and dysphagia with poor response to medical therapy. Physical examination revealed no significant findings. The lung transplant surgical team determined the patient was not a candidate given the severity of the GERD, due to a high risk of primary graft dysfunction. This led to a medical committee deciding an open total gastrectomy with roux-en-Y anastomosis prior to lung transplant for this particular case. This case report reveals a surgical alternative in patients with GERD secondary to scleroderma despite a high risk of disease recurrence.\nFollow-up one week later with esophagogram revealed normal esophageal morphology, no stenosis or motility difficulties, adequate esophago-jejunal anastomosis diameter, no extravasation of the contrast medium and an adequate transit of the medium to the small intestine. There is no evidence of reflux of the medium . In out-patient consult, an upper gastrointestinal endoscopy is performed within a 3-month period which revealed mild esophago-jejunal anastomosis stricture resolving after three balloon dilations of 11 mm, 15 mm, and 18 mm, respectively (, , ). Currently, the patient continues follow-up consults, with an adequate postoperative state, asymptomatic according to the Gastroesophageal Reflux Disease Health Related Quality of Life (GERD-HRQL) instrument and currently awaits lung transplant.", + "fulltext_subclaims": [ + "The patient is a 56-year-old female.", + "The patient has a body mass index of 22.5 kg/m2.", + "The patient has a previous clinical history of diffuse scleroderma.", + "The patient has intestinal pneumonitis.", + "The patient has mild pulmonary hypertension.", + "The patient has secondary gastroesophageal reflux.", + "The patient has severe esophageal motility disease.", + "The patient is receiving immunosuppression, antihypertensive, proton pump inhibitor, and prokinetic management.", + "The patient has a weak response to medical therapy.", + "The patient is admitted for surgical management after a 1-year follow-up with cardiology, pneumology, and gastroenterology.", + "The patient has a previous diagnosis of esophageal aperistalsis.", + "The patient has dysphagia.", + "The patient has poor response to medical therapy.", + "Physical examination revealed no significant findings.", + "The lung transplant surgical team determined the patient was not a candidate given the severity of the GERD.", + "The medical committee decided an open total gastrectomy with roux-en-Y anastomosis prior to lung transplant.", + "Follow-up one week later with esophagogram revealed normal esophageal morphology.", + "Follow-up one week later with esophagogram revealed no stenosis.", + "Follow-up one week later with esophagogram revealed adequate esophago-jejunal anastomosis diameter.", + "Follow-up one week later with esophagogram revealed no extravasation of the contrast medium.", + "Follow-up one week later with esophagogram revealed adequate transit of the medium to the small intestine.", + "Follow-up one week later with esophagogram revealed no evidence of reflux of the medium.", + "An upper gastrointestinal endoscopy is performed within a 3-month period.", + "The upper gastrointestinal endoscopy revealed mild esophago-jejunal anastomosis stricture.", + "The stricture resolved after three balloon dilations of 11 mm, 15 mm, and 18 mm, respectively.", + "The patient continues follow-up consults.", + "The patient is asymptomatic according to the Gastroesophageal Reflux Disease Health Related Quality of Life (GERD-HRQL) instrument.", + "The patient currently awaits lung transplant." + ], + "summary": "A 56-year-old female, with previous history of intestinal pneumonitis, mild pulmonary hypertension and gastroesophageal reflux secondary to systemic scleroderma, is considered for lung transplant. Initially, due to persistent gastroesophageal reflux, a transplant was not a viable. This was corrected with an open gastrectomy with roux-en-Y anastomosis. Follow-up one week later revealed normal anatomy, adequate esophageal-jejunal anastomosis, and adequate contrast medium transit via esophagogram. Additionally, there was no evidence of contrast medium reflux indicating a resolved gastroesophageal reflux disease. This led to the patient becoming a candidate for lung transplant.", + "summary_subclaims": [ + "The patient is a 56-year-old female.", + "The patient has a previous history of intestinal pneumonitis.", + "The patient has mild pulmonary hypertension.", + "The patient has gastroesophageal reflux secondary to systemic scleroderma.", + "A lung transplant was initially not a viable option due to persistent gastroesophageal reflux.", + "An open gastrectomy with roux-en-Y anastomosis was performed.", + "Follow-up one week later revealed normal anatomy.", + "Follow-up one week later showed an adequate esophageal-jejunal anastomosis.", + "Follow-up one week later showed adequate contrast medium transit via esophagogram.", + "There was no evidence of contrast medium reflux.", + "This led to the patient becoming a candidate for lung transplant." + ] + }, + { + "id": "multiclinsum_test_2761_en.txt", + "fulltext": "A 22-year-old Caucasian female was seen in the neurosurgical outpatient clinic. The family history was irrelevant. Her medical history revealed a congenital anal atresia and an ectopic anus. At the age of 3 years, the latter was corrected with an anterior sagittal anorectoplasty (ASARP) procedure. Furthermore, she had suffered from grade III vesico-ureteral reflux. X-ray imaging of the lumbar spine confirmed a partial sacral agenesis, sickle-shaped sacrum . After surgery, constipation resolved without fecal incontinence. She was followed-up by the pediatric surgeon. Otherwise, she was in healthy condition and is currently employed as a registered nurse.\nDuring the second part of 2010, she experienced transient defecation difficulties. For that reason, the pediatric surgical team performed an MRI without contrast of the pelvic region. This showed the formerly known changes as expected from the ASARP procedure and the partial sacral agenesis. Coincidentally an anterior presacral mass of unknown origin, suggestive of a meningocele, as well as a bicornuate uterus was diagnosed . Neurological examination did not reveal any deficits, explicitly there were neither pyramidal tract nor posterior column signs. The history of anorectal malformations, partial sacral agenesis and the presacral meningocele should prompt to the diagnosis of Currarino’s triad. This syndrome can be accompanied by a tethered cord, and a presacral mass of another origin, such as a teratoma. Therefore, we decided to perform a contrast-enhanced MRI of the lumbosacral spine, to rule out any of the above. It confirmed the presacral mass to be a meningocele. Furthermore, a moderate tethered cord was observed with the medullary conus at level L3–4, as well as a small syrinx. The radiologic findings and the absence of symptoms showed no need for surgical intervention. We decided to pursue a conservative approach and follow her in the outpatient clinic. If complaints or neurological symptoms should occur, depending on the incident pathology, transdural ligation of the meningocele or untethering of the spinal cord could be considered. Genetic counseling was initiated.", + "fulltext_subclaims": [ + "The patient is a 22-year-old Caucasian female.", + "The family history was irrelevant.", + "Her medical history revealed a congenital anal atresia.", + "Her medical history revealed an ectopic anus.", + "At the age of 3 years, the ectopic anus was corrected with an anterior sagittal anorectoplasty (ASARP) procedure.", + "She had suffered from grade III vesico-ureteral reflux.", + "X-ray imaging of the lumbar spine confirmed a partial sacral agenesis.", + "X-ray imaging of the lumbar spine confirmed a sickle-shaped sacrum.", + "After surgery, constipation resolved without fecal incontinence.", + "She was followed-up by the pediatric surgeon.", + "She is currently employed as a registered nurse.", + "During the second part of 2010, she experienced transient defecation difficulties.", + "The pediatric surgical team performed an MRI without contrast of the pelvic region.", + "The MRI showed the formerly known changes as expected from the ASARP procedure.", + "The MRI showed the formerly known changes as expected from the partial sacral agenesis.", + "An anterior presacral mass of unknown origin, suggestive of a meningocele, was diagnosed.", + "A bicornuate uterus was diagnosed.", + "Neurological examination did not reveal any deficits.", + "There were neither pyramidal tract nor posterior column signs.", + "The history of anorectal malformations, partial sacral agenesis and the presacral meningocele should prompt to the diagnosis of Currarino’s triad.", + "The syndrome can be accompanied by a tethered cord.", + "The syndrome can be accompanied by a presacral mass of another origin, such as a teratoma.", + "A contrast-enhanced MRI of the lumbosacral spine was performed.", + "The MRI confirmed the presacral mass to be a meningocele.", + "A moderate tethered cord was observed with the medullary conus at level L3–4.", + "A small syrinx was observed.", + "The radiologic findings and the absence of symptoms showed no need for surgical intervention.", + "A conservative approach was decided.", + "If complaints or neurological symptoms should occur, transdural ligation of the meningocele or untethering of the spinal cord could be considered.", + "Genetic counseling was initiated." + ], + "summary": "This case presents an adult patient with a medical history of a congenital anal atresia, a partial sacral agenesis, and a surgically treated ectopic anus. After a coincidentally observed presacral mass by MRI, due to unexplained constipation later in adulthood, Currarino's triad was suspected in this patient. This triad consists of anorectal malformation(s), sacrococcygeal defects and a presacral mass of various origin. Further investigation confirmed the mass to be a meningocele, and showed a tethered cord and a syrinx.", + "summary_subclaims": [ + "The patient is an adult.", + "The patient has a medical history of a congenital anal atresia.", + "The patient has a partial sacral agenesis.", + "The patient had a surgically treated ectopic anus.", + "A presacral mass was observed by MRI.", + "The MRI was performed due to unexplained constipation.", + "The presacral mass was observed later in adulthood.", + "Currarino's triad was suspected in this patient.", + "Currarino's triad consists of anorectal malformation(s), sacrococcygeal defects and a presacral mass of various origin.", + "Further investigation confirmed the mass to be a meningocele.", + "The investigation showed a tethered cord.", + "The investigation showed a syrinx." + ] + }, + { + "id": "multiclinsum_test_1688_en.txt", + "fulltext": "In September 2011 a 51-year-old Caucasian woman with a history of psoriasis and type-2 diabetes mellitus developed a mild psoriasis together with dactylitis affecting the right fourth finger and arthritis of the fourth metacarpophalangeal (MCP) joint of the right hand. In November 2011 she was referred our outpatient clinic. Dactylitis of the fourth finger of the right hand and swelling, redness and pain of the distal interphalangeal (DIP) joint of the second digit of the right hand were noted during the physical examination. Laboratory results at that time included: Erythrocyte sedimentation rate (ESR) = 100 mm/h (normal range 0–39 mm/h), C-reactive protein (CRP) = 3.99 mg/l (normal range 0–6 mg/l), gamma-glutamyltransferase (γGT) = 237 IU/l (normal range 3–45 IU/ml), and alkaline phosphatase (ALP) = 201 IU/l (normal range 53–141 IU/ml). The patient was treated with methylprednisolone for 6 months; treatment was started with doses of 16 mg/die that were tapered to 4 mg/die. She also received 15 mg weekly oral Methotrexate (MTX) for 6 months beginning in May 2012 with poor results. In March 2012, hand X-rays uncovered periostitis of the proximal phalanx of the right fourth digit; ultrasound (US) and powerdoppler evaluation revealed flexor tenosynovitis of the fourth finger of the right hand and a small erosion in the head of the fourth MCF of the right hand. An US-guided corticosteroid injection of the tendon sheath was adminstered.\nIn April 2012 the patient presented to the Gastroenterology Unit of the University of Padova Medical Centre. Biochemical testing confirmed abnormal cholestatic patterns that had been persisting since 2009 (γGT 229 IU/ml and ALP 201 IU/ml). At that time the patient showed: antimitochondrial antibody (AMA) positivity in immunofluorescence with a 1:160 titre, immunoblotting positivity for M2, 3E and anti pg 210, total serum cholesterol = 240 mg/dl (range ≤ 200 mg/dl), serum IgM = 7.31 g/L (range 0.4–2.38 g/L), normal transaminases, negative hepatitis B and C serum markers. The patient showed no symptom of cholestasis; the liver and spleen were not palpable. A liver biopsy, which was performed in May 2012, showed marked fibrosis of the portal tracts extending to the parenchyma, interface hepatitis, and a vanishing bile duct picture with the remaining ducts showing regressive alterations of cholangiocytes together with biliary metaplasia. The histological picture was compatible with stage III PBC. Ursodeoxycholic acid (UDCA), which was begun in April 2012 at 10 mg/Kg/day, was later increased to 15 mg/Kg/day; a partial reduction in γGT and ALP was recorded. In July 2012, the patient underwent Magnetic Resonance Imaging (MRI) cholangiography of the upper abdomen which revealed a marked reduction of the right segmental duct extended for 2.5 cm, with upstream dilatation, and pronounced stenosis of the biliary tree in the 5th and 6th hepatic segment considered characteristic of PSC. MRI typically shows multiple strictures and dilatations of the intrahepatic biliary tree in PSC patients. In our case, the coexistence of a liver biopsy compatible with PBC and MRI results typical of PSC permitted us to formulate a diagnosis of PBC-PSC overlap syndrome.\nGiven the absence of both the histopathological features of IgG4-related disease and abundant IgG4+ plasma cells in the liver biopsy material, the hypothesis of IgG4-associated cholangitis was excluded. Furthermore, there were no signs of synchronous involvement of other organs.\nIn October 2012, arthritis of the fourth right DIP joint and severe nail psoriasis were two new symptoms that were added to the clinical picture . Hand X-rays showed new erosions in the fourth right MCF and DIP . Adalimumab treatment (40 mg fortnightly), which was begun at that time, led to notable relief of the pain and stiffness. Three months later the painful swellings of the second and fourth right DIP joints showed marked improvement, and the nail of the fourth right finger appeared normal . The patient’s Health Assessment Questionnaire (HAQ) disability index score fell from 0.750 to 0.375, the Disease Activity Score 28 (DAS28) fell from 4.25 to 3.18 and the Disease Activity in Psoriatic Arthritis (DAPSA) score fell from 17.37 to 4.29. Liver function tests improved, the ALP normalized, and the γGT and IgM improved (respectively falling to 124 IU/L and 5.35 g/L). Twelve months later, the HAQ continued to fall reaching 0.25, the DAS 28 fell to 1.80, and the DAPSA to 2.69. Hand X-rays showed that the bone erosion infourth right DIP joint seemed to have disappeared while the erosion at the base of the first phalanx persisted . Unfortunately, we do not have Computerized Tomography (CT) or MRI confirmation of these findings. Twenty-eight months later, the patient’s HAQ and DAS 28 values were stable, the DAPSA was 5.29 (low disease activity), the γGT and serum IgM had fallen even further (respectively reaching 98 IU/ml, and 4.93 g/L), and the ALP remained at normal levels (107 IU/ml) . At present, the patient continues to receive Adalimumab and enjoys good health.", + "fulltext_subclaims": [ + "The patient is a 51-year-old Caucasian woman.", + "She has a history of psoriasis and type-2 diabetes mellitus.", + "In September 2011, she developed mild psoriasis.", + "In September 2011, she had dactylitis affecting the right fourth finger.", + "In September 2011, she had arthritis of the fourth metacarpophalangeal (MCP) joint of the right hand.", + "In November 2011, she was referred to an outpatient clinic.", + "During the physical examination, dactylitis of the fourth finger of the right hand was noted.", + "During the physical examination, swelling, redness, and pain of the distal interphalangeal (DIP) joint of the second digit of the right hand were noted.", + "The Erythrocyte sedimentation rate (ESR) was 100 mm/h.", + "The C-reactive protein (CRP) was 3.99 mg/l.", + "The gamma-glutamyltransferase (γGT) was 237 IU/l.", + "The alkaline phosphatase (ALP) was 201 IU/l.", + "She was treated with methylprednisolone for 6 months.", + "Methylprednisolone treatment started with doses of 16 mg/die.", + "Methylprednisolone doses were tapered to 4 mg/die.", + "She received 15 mg weekly oral Methotrexate (MTX) for 6 months beginning in May 2012.", + "The Methotrexate treatment had poor results.", + "In March 2012, hand X-rays showed periostitis of the proximal phalanx of the right fourth digit.", + "An ultrasound (US) and powerdoppler evaluation revealed flexor tenosynovitis of the fourth finger of the right hand.", + "An ultrasound-guided corticosteroid injection of the tendon sheath was administered.", + "In April 2012, the patient presented to the Gastroenterology Unit of the University of Padova Medical Centre.", + "Biochemical testing confirmed abnormal cholestatic patterns that had been persisting since 2009.", + "The patient showed antimitochondrial antibody (AMA) positivity in immunofluorescence with a 1:160 titre.", + "The patient showed immunoblotting positivity for M2, 3E, and anti pg 210.", + "The patient’s total serum cholesterol was 240 mg/dl.", + "The patient’s serum IgM was 7.31 g/L.", + "The patient had normal transaminases.", + "The patient had negative hepatitis B and C serum markers.", + "The patient showed no symptoms of cholestasis.", + "The liver and spleen were not palpable.", + "A liver biopsy performed in May 2012 showed marked fibrosis of the portal tracts extending to the parenchyma.", + "The liver biopsy showed interface hepatitis.", + "The liver biopsy showed a vanishing bile duct picture with the remaining ducts showing regressive alterations of cholangiocytes.", + "The liver biopsy showed biliary metaplasia.", + "The histological picture was compatible with stage III primary biliary cholangitis (PBC).", + "Ursodeoxycholic acid (UDCA) was begun in April 2012 at 10 mg/Kg/day.", + "UDCA was later increased to 15 mg/Kg/day.", + "A partial reduction in γGT and ALP was recorded.", + "In July 2012, the patient underwent Magnetic Resonance Imaging (MRI) cholangiography of the upper abdomen.", + "MRI showed a marked reduction of the right segmental duct extended for 2.5 cm.", + "MRI showed upstream dilatation.", + "MRI showed pronounced stenosis of the biliary tree in the 5th and 6th hepatic segment.", + "MRI findings were considered characteristic of primary sclerosing cholangitis (PSC).", + "MRI typically shows multiple strictures and dilatations of the intrahepatic biliary tree in PSC patients.", + "The coexistence of a liver biopsy compatible with PBC and MRI results typical of PSC permitted the diagnosis of PBC-PSC overlap syndrome.", + "The hypothesis of IgG4-associated cholangitis was excluded.", + "There were no signs of synchronous involvement of other organs.", + "In October 2012, arthritis of the fourth right DIP joint was a new symptom.", + "In October 2012, severe nail psoriasis was a new symptom.", + "Hand X-rays showed new erosions in the fourth right MCF and DIP.", + "Adalimumab treatment (40 mg fortnightly) was begun at that time.", + "Adalimumab treatment led to notable relief of the pain and stiffness.", + "Three months later, the painful swellings of the second and fourth right DIP joints showed marked improvement.", + "Three months later, the nail of the fourth right finger appeared normal.", + "The patient’s Health Assessment Questionnaire (HAQ) disability index score fell from 0.750 to 0.375.", + "The Disease Activity Score 28 (DAS28) fell from 4.25 to 3.18.", + "The Disease Activity in Psoriatic Arthritis (DAPSA) score fell from 17.37 to 4.29.", + "Liver function tests improved.", + "The ALP normalized.", + "The γGT and IgM improved, respectively falling to 124 IU/L and 5.35 g/L.", + "Twelve months later, the HAQ continued to fall, reaching 0.25.", + "Twelve months later, the DAS 28 fell to 1.80.", + "Twelve months later, the DAPSA fell to 2.69.", + "Hand X-rays showed that the bone erosion in the fourth right DIP joint seemed to have disappeared.", + "The erosion at the base of the first phalanx persisted.", + "We do not have Computerized Tomography (CT) or MRI confirmation of these findings.", + "Twenty-eight months later, the patient’s HAQ and DAS 28 values were stable.", + "Twenty-eight months later, the DAPSA was 5.29 (low disease activity).", + "Twenty-eight months later, the γGT and serum IgM had fallen even further, respectively reaching 98 IU/ml and 4.93 g/L.", + "Twenty-eight months later, the ALP remained at normal levels (107 IU/ml).", + "At present, the patient continues to receive Adalimumab.", + "At present, the patient enjoys good health." + ], + "summary": "We report the case of a 51-year-old female affected with psoriatic arthritis concomitant to overlapping primary biliary cholangitis and primary sclerosing cholangitis in whom 28 months of adalimumab treatment improved the symptoms of the inflammatory arthropathy as well as those of both cholangiopathies.", + "summary_subclaims": [ + "The patient was a 51-year-old female.", + "The patient was affected with psoriatic arthritis.", + "The patient had overlapping primary biliary cholangitis.", + "The patient had primary sclerosing cholangitis.", + "The patient received 28 months of adalimumab treatment.", + "The treatment improved the symptoms of the inflammatory arthropathy.", + "The treatment improved the symptoms of both cholangiopathies." + ] + }, + { + "id": "multiclinsum_test_1553_en.txt", + "fulltext": "A 27-year-old woman visited our gynecology department because of abdominal pain and genital bleeding. Magnetic resonance imaging (MRI) revealed a cystic mass in the left retrorectal area, and she was referred to our department for detailed examinations and treatment. Her medical history was unremarkable. Her laboratory results, including serum tumor biomarkers, such as α-fetoprotein (AFP), carcinogenic embryonic antigen (CEA) and carbohydrate antigen 19-9 (CA19-9), were within normal limits. Computed tomography (CT) showed a 3-cm-sized multilocular cystic mass in the anterior sacrum on the left dorsal side of the rectum. The mass showed a gradual contrast effect on the margin and was suspected to have a solid component. No obvious calcification was observed . MRI showed no obvious fat in the area . Fluorodeoxyglucose-position emission tomography (FDG-PET) showed no abnormal uptake. Lower gastrointestinal endoscopy showed no abnormalities in the rectal mucosa. Endoscopic ultrasound (EUS) showed a 3-cm-sized extraintestinal cyst near the rectum. No obvious calcification was found inside .\nWith the above tests, it was difficult to confirm the preoperative diagnosis of the presacral cystic mass. Teratoma, tailgut cyst, dermoid cyst, epidermoid cyst, etc., were considered in the differential diagnosis. Because there have been reports of malignant cases, we decided to perform surgical mass removal as a diagnostic treatment.\nThe operation was conducted with the patient in the jack-knife position. A skin incision measuring approximately 3 cm was made from the coccyx to the anus. We made an incision in the mural fascia to reach the tumor and enable detachment without damaging the tumor. Since it was difficult to confirm the deep part of the tumor through direct visualization, we attached a GelPOINT® Path (Applied Medical, USA) placed two 10-mm trocars and a AirSEAL® (CONMED, USA) trocar in a triangular fashion to the incision and insufflated it at 12 mmHg with the AirSEAL® System to remove the tumor endoscopically while confirming the boundary between the tumor and the anterior coccyx/posterior rectal wall. The operative time was 171 min, with minimal blood loss .\nHistopathological examination revealed a benign mature teratoma . She did not have any complications and was discharged from our hospital 5 days after the surgery. Seven months later, she had no tumor recurrence or residual symptoms.", + "fulltext_subclaims": [ + "The patient is a 27-year-old woman.", + "She visited the gynecology department because of abdominal pain and genital bleeding.", + "MRI revealed a cystic mass in the left retrorectal area.", + "She was referred to the department for detailed examinations and treatment.", + "Her medical history was unremarkable.", + "Her laboratory results, including serum tumor biomarkers, were within normal limits.", + "CT showed a 3-cm-sized multilocular cystic mass in the anterior sacrum on the left dorsal side of the rectum.", + "The mass showed a gradual contrast effect on the margin.", + "The mass was suspected to have a solid component.", + "No obvious calcification was observed.", + "MRI showed no obvious fat in the area.", + "FDG-PET showed no abnormal uptake.", + "Lower gastrointestinal endoscopy showed no abnormalities in the rectal mucosa.", + "EUS showed a 3-cm-sized extraintestinal cyst near the rectum.", + "No obvious calcification was found inside.", + "It was difficult to confirm the preoperative diagnosis of the presacral cystic mass.", + "Teratoma, tailgut cyst, dermoid cyst, epidermoid cyst, etc., were considered in the differential diagnosis.", + "Because there have been reports of malignant cases, surgical mass removal was decided as a diagnostic treatment.", + "The operation was conducted with the patient in the jack-knife position.", + "A skin incision measuring approximately 3 cm was made from the coccyx to the anus.", + "A GelPOINT® Path was placed and two 10-mm trocars and an AirSEAL® trocar were inserted.", + "The tumor was removed endoscopically while confirming the boundary between the tumor and the anterior coccyx/posterior rectal wall.", + "The operative time was 171 min.", + "Histopathological examination revealed a benign mature teratoma.", + "She was discharged from the hospital 5 days after the surgery.", + "Seven months later, she had no tumor recurrence or residual symptoms." + ], + "summary": "A 27-year-old woman visited our gynecology department because of abdominal pain and genital bleeding. Magnetic resonance imaging (MRI) revealed a 3-cm-sized cystic mass in the left retrorectal area, and she was referred to our department for detailed examinations and treatment. She was diagnosed with a presacral cystic tumor and decided to undergo surgery. We used a transsacral approach to perform tumor excision. Since it was difficult to confirm the deep part of the tumor through direct visualization, we used GelPOINT® Path (a transanal access platform) and AirSEAL® System (insufflation device) to remove the tumor endoscopically. The postoperative course was uneventful with no bladder or rectal dysfunction. Histopathological examination revealed a mature teratoma.", + "summary_subclaims": [ + "The patient was a 27-year-old woman.", + "She visited the gynecology department because of abdominal pain and genital bleeding.", + "MRI revealed a 3-cm-sized cystic mass in the left retrorectal area.", + "She was referred to the department for detailed examinations and treatment.", + "She was diagnosed with a presacral cystic tumor.", + "She decided to undergo surgery.", + "A transsacral approach was used to perform tumor excision.", + "It was difficult to confirm the deep part of the tumor through direct visualization.", + "GelPOINT® Path was used to remove the tumor endoscopically.", + "AirSEAL® System was used to remove the tumor endoscopically.", + "The postoperative course was uneventful with no bladder or rectal dysfunction.", + "Histopathological examination revealed a mature teratoma." + ] + }, + { + "id": "multiclinsum_test_3348_en.txt", + "fulltext": "The index case is that of an 18-year-old primigravida who was referred to the antenatal testing center for a growth scan at 35 weeks and 5 days gestation, due to lagging symphysio-fundal height measurement. She had no significant past medical history, and her antenatal course was uncomplicated. A detailed ultrasound scan was done and revealed a normal fetus with estimated fetal weight that was appropriate for gestational age, normal amniotic fluid index and a posterior placenta with a 3-vessel umbilical cord. There was a cystic structure with internal echoes, originating from the placenta at the point of the umbilical cord insertion, which was determined to be a 1.9 × 1.8 cm umbilical artery aneurysm on 3D and Doppler imaging. On subsequent imaging 3 days later at 36 weeks and 1 day, the aneurysm was noted to measure 3.06 × 1.79 cm, an increase in size from prior measurement. Umbilical artery Doppler studies were within normal limits. The middle cerebral artery peak systolic volume calculated was 1.04 MoM, which was at the higher end of the normal range. Fetal echocardiogram was done and revealed normal cardiac evaluation, with no abnormality detected in the ductus venosus velocimetry.\n\nDue to the increase in size of the aneurysm over a short interval, the patient was counseled regarding the risks of intra-uterine fetal demise and was transferred to the labor and delivery unit. Fetal monitoring via non-stress test revealed fetal tachycardia, with a baseline heart rate above 165 bpm and regular uterine contractions. Her calculated Bishop score was 2, she was remote from delivery with a category 2 tracing, and a potentially compromised fetus. The decision was then made to proceed with cesarean section delivery. A live female infant was delivered weighing 2,850 g; Apgar scores were 7 at 1 min and 9 at 5 min. The baby was admitted to the special care nursery for observation due to transient tachypnea. The newborn hemoglobin was 15.8 g/dL. Karyotyping subsequently revealed 46 XX.\n\nOn pathological examination, the placenta was ovoid in shape with an eccentrically inserted 22 cm long 3-vessel edematous umbilical cord. There was a 2.5 × 2.4 × 1.2 cm dilated intact vessel containing a soft dark red blood clot, approximately 0.4 cm from the base of the umbilical cord. Surrounding the blood vessel was a 7.0 × 6.0 cm ovoid pale tan area. The umbilical artery aneurysm was confirmed at the point of insertion onto the placental disc. Microscopic and macroscopic chorionic pseudocysts were also noted.", + "fulltext_subclaims": [ + "The index case is that of an 18-year-old primigravida.", + "She was referred to the antenatal testing center for a growth scan at 35 weeks and 5 days gestation.", + "The referral was due to lagging symphysio-fundal height measurement.", + "She had no significant past medical history.", + "Her antenatal course was uncomplicated.", + "A detailed ultrasound scan was done.", + "The ultrasound scan revealed a normal fetus.", + "The estimated fetal weight was appropriate for gestational age.", + "The amniotic fluid index was normal.", + "There was a posterior placenta.", + "There was a 3-vessel umbilical cord.", + "There was a cystic structure with internal echoes, originating from the placenta at the point of the umbilical cord insertion.", + "The cystic structure was determined to be a 1.9 × 1.8 cm umbilical artery aneurysm on 3D and Doppler imaging.", + "On subsequent imaging 3 days later at 36 weeks and 1 day, the aneurysm was noted to measure 3.06 × 1.79 cm.", + "The aneurysm was noted to increase in size from prior measurement.", + "Umbilical artery Doppler studies were within normal limits.", + "The middle cerebral artery peak systolic volume calculated was 1.04 MoM.", + "The middle cerebral artery peak systolic volume was at the higher end of the normal range.", + "A fetal echocardiogram was done.", + "The fetal echocardiogram revealed normal cardiac evaluation.", + "No abnormality was detected in the ductus venosus velocimetry.", + "The patient was counseled regarding the risks of intra-uterine fetal demise.", + "The patient was transferred to the labor and delivery unit.", + "Fetal monitoring via non-stress test revealed fetal tachycardia.", + "The baseline fetal heart rate was above 165 bpm.", + "There were regular uterine contractions.", + "The calculated Bishop score was 2.", + "The patient was remote from delivery.", + "The fetal heart rate tracing was category 2.", + "The fetus was potentially compromised.", + "The decision was made to proceed with cesarean section delivery.", + "A live female infant was delivered.", + "The infant weighed 2,850 g.", + "The Apgar score was 7 at 1 min.", + "The Apgar score was 9 at 5 min.", + "The baby was admitted to the special care nursery for observation.", + "The baby was admitted due to transient tachypnea.", + "The newborn hemoglobin was 15.8 g/dL.", + "Karyotyping revealed 46 XX.", + "The placenta was ovoid in shape.", + "The umbilical cord was eccentrically inserted.", + "The umbilical cord was 22 cm long.", + "The umbilical cord was 3-vessel.", + "The umbilical cord was edematous.", + "There was a 2.5 × 2.4 × 1.2 cm dilated intact vessel containing a soft dark red blood clot.", + "The blood clot was approximately 0.4 cm from the base of the umbilical cord.", + "There was a 7.0 × 6.0 cm ovoid pale tan area surrounding the blood vessel.", + "The umbilical artery aneurysm was confirmed at the point of insertion onto the placental disc.", + "Microscopic and macroscopic chorionic pseudocysts were noted." + ], + "summary": "The index case is an 18-year-old primigravida who had an ultrasound at 35 weeks and 5 days gestation due to lagging symphysio-fundal height measurement. The ultrasound scan revealed a normal fetus with estimated fetal weight that was appropriate for gestational age. There was a cystic structure with internal echoes originating from the placenta at the point of the umbilical cord insertion, which was determined to be a 1.9 × 1.8 cm umbilical artery aneurysm on 3D and Doppler imaging. On follow up imaging the aneurysm had increased in size and measured 3.06 × 1.79 cm. The patient subsequently had a cesarean section delivery of a live female. Karyotyping subsequently revealed 46 XX.", + "summary_subclaims": [ + "The index case is an 18-year-old primigravida.", + "The ultrasound was performed at 35 weeks and 5 days gestation.", + "The ultrasound was due to lagging symphysio-fundal height measurement.", + "The ultrasound scan revealed a normal fetus.", + "The estimated fetal weight was appropriate for gestational age.", + "There was a cystic structure with internal echoes originating from the placenta at the point of the umbilical cord insertion.", + "The cystic structure was determined to be a 1.9 × 1.8 cm umbilical artery aneurysm on 3D and Doppler imaging.", + "On follow up imaging the aneurysm had increased in size and measured 3.06 × 1.79 cm.", + "The patient had a cesarean section delivery of a live female.", + "Karyotyping revealed 46 XX." + ] + }, + { + "id": "multiclinsum_test_1233_en.txt", + "fulltext": "On January 31, 2015, a 43-year-old Asian man with a 3-year history of progressively invasive PC presented with pain in his right eye. Our patient, who had been staged T4N3M1(TNM classification), had also lost his vision more than a month earlier. He was diagnosed as having metastasis in the bilateral inguinal lymph nodes and ipsilateral iliac nodes before systemic metastasis to his liver and lungs. His medical history was remarkable due to his several surgeries. He denied any family history of inherited diseases and psychological illness.\nOn presentation, his best corrected visual acuity was no light perception in his right eye and 20/20 in his left eye. His intraocular pressures were 13.0 mmHg and 11.0 mmHg in his right and left eye, respectively. For the right eye, the pupil dilated to 5 mm, and then the pupillary reaction disappeared. An external examination revealed mild proptosis and ocular movement in all directions. A dilated fundus examination of his right eye showed post equatorial retinal detachment with a black eminence and a pale optic disk. There were no obvious abnormalities in his left eye.\nAn ophthalmic B-scan ultrasound showed retinal detachment with hemorrhage. Orbital MRI confirmed the thickening and strengthening of the right lateral wall, characteristics of metastatic carcinoma. The internal rectus and lateral rectus muscles were thickened and hardened, the 2-cm-long optic nerve was thickened, and its stump was invaded by the metastasis. The T1-weighted images of the MRI scans showed hyperintensity , whereas the T2-weighted images showed hypointensity . A contrast-enhanced MRI scan revealed inhomogeneous enhancement of the posterior wall . The presence of lesions was associated with invasion of the optic nerve, choroid, and sclera by the metastatic cells.\nThe deep layer, including the choroid, was infiltrated by cancerous tissue. Considering his severe eye pain and irreversible loss of vision, our patient had undergone right eyeball enucleation under general anesthesia on February 3, 2015. This type of procedure is indicated for patients who have had severe eye trauma and for those patients experiencing severe eye pain with unrecoverable vision. His complete eyeball was observed intraoperatively. Histopathological examination led to a diagnosis of metastatic moderately differentiated penile squamous cell carcinoma that infiltrated the sclera, choroid, retina, optic nerve, and external intraocular sites. Hematoxylin-and-eosin staining of the entire eyeball cellular neoplasm showed keratin pearls and infiltrative growth of keratinized cells. Intercellular bridges were seen in the nests of moderately differentiated squamous carcinoma cells .\nOur patient received chemotherapy and radiotherapy during 6 months of follow-up, and then died due to brain metastasis.", + "fulltext_subclaims": [ + "The patient was a 43-year-old Asian man.", + "He had a 3-year history of progressively invasive PC.", + "He presented with pain in his right eye.", + "He had been staged T4N3M1 (TNM classification).", + "He had lost his vision more than a month earlier.", + "He was diagnosed as having metastasis in the bilateral inguinal lymph nodes.", + "He had ipsilateral iliac node metastasis.", + "He had systemic metastasis to his liver and lungs.", + "His medical history was remarkable due to several surgeries.", + "He denied any family history of inherited diseases.", + "He denied any psychological illness.", + "On presentation, his best corrected visual acuity was no light perception in his right eye.", + "On presentation, his best corrected visual acuity was 20/20 in his left eye.", + "His intraocular pressure was 13.0 mmHg in his right eye.", + "His intraocular pressure was 11.0 mmHg in his left eye.", + "The right eye pupil dilated to 5 mm.", + "The right eye pupillary reaction disappeared.", + "An external examination revealed mild proptosis.", + "A dilated fundus examination of his right eye showed post equatorial retinal detachment.", + "A dilated fundus examination showed a black eminence.", + "A dilated fundus examination showed a pale optic disk.", + "There were no obvious abnormalities in his left eye.", + "An ophthalmic B-scan ultrasound showed retinal detachment with hemorrhage.", + "Orbital MRI confirmed thickening and strengthening of the right lateral wall.", + "The internal rectus and lateral rectus muscles were thickened and hardened.", + "The 2-cm-long optic nerve was thickened.", + "The optic nerve stump was invaded by the metastasis.", + "T1-weighted images showed hyperintensity.", + "T2-weighted images showed hypointensity.", + "A contrast-enhanced MRI scan revealed inhomogeneous enhancement of the posterior wall.", + "The presence of lesions was associated with invasion of the optic nerve.", + "The presence of lesions was associated with invasion of the choroid.", + "The presence of lesions was associated with invasion of the sclera.", + "The deep layer, including the choroid, was infiltrated by cancerous tissue.", + "The patient had undergone right eyeball enucleation on February 3, 2015.", + "The procedure was under general anesthesia.", + "Histopathological examination led to a diagnosis of metastatic moderately differentiated penile squamous cell carcinoma.", + "The cancer infiltrated the sclera.", + "The cancer infiltrated the choroid.", + "The cancer infiltrated the retina.", + "The cancer infiltrated the optic nerve.", + "The cancer infiltrated external intraocular sites.", + "Hematoxylin-and-eosin staining showed keratin pearls.", + "Hematoxylin-and-eosin staining showed infiltrative growth of keratinized cells.", + "Intercellular bridges were seen in the nests of moderately differentiated squamous carcinoma cells.", + "The patient received chemotherapy and radiotherapy during 6 months of follow-up.", + "The patient died due to brain metastasis." + ], + "summary": "A 43-year-old Asian man with a 3-year history of penile cancer presented with metastasis in the right intraocular sites. Magnetic resonance imaging showed hyperintensity in the T1-weighted images and hypointensity in the T2-weighted images of the right eye. After enucleation of his right eye, histopathological analysis led to a diagnosis of metastatic, moderately differentiated penile squamous cell carcinoma.", + "summary_subclaims": [ + "The patient is a 43-year-old Asian man.", + "The patient has a 3-year history of penile cancer.", + "The patient presented with metastasis in the right intraocular sites.", + "Magnetic resonance imaging showed hyperintensity in the T1-weighted images of the right eye.", + "Magnetic resonance imaging showed hypointensity in the T2-weighted images of the right eye.", + "The patient underwent enucleation of his right eye.", + "Histopathological analysis led to a diagnosis of metastatic, moderately differentiated penile squamous cell carcinoma." + ] + }, + { + "id": "multiclinsum_test_1948_en.txt", + "fulltext": "A 54-year-old male experiencing acute onset of numbness and weakness in his left limb was admitted to the First Affiliated Hospital of Guangxi Medical University on Nov. 1, 2020. Initial magnetic resonance imaging (MRI) of the brain showed abnormal signals in the right parietal lobe. Brain computed tomography (CT) and enhanced MRI on Nov. 10 showed an ill-defined infiltrating enhanced mass in the right parietal lobe with perilesional edema, which pointed to the possibility of a low-grade glioma. Resection of the mass in the right parietal lobe was performed on Nov. 12. The specimen exhibited granulomatous changes and inflammatory perivascular infiltrate with positive CD68 staining, negative acid-fast, periodic acid-achiff and CD235a staining. The patient consequently received antibiotic therapy: intravenous Linezolid (0.2 g twice daily for 9 days). His left limb weakness improved slightly, as seen in his activity of daily living (ADL) scores. The ADL score was 75 after the surgery in comparison to 70 before the surgery. However, the patient had a headache accompanied by diplopia and difficulty walking when he was taking hyperbaric oxygen therapy on Nov. 28. An emergency head CT on Dec. 2 showed that a new low-density focus occurred in the left occipital lobe . The blood tests on Dec. 5 revealed that erythrocyte sedimentation rate was 31 mm/h (0–15), hypersensitive C-reactive protein was 0.8 mg/L (0-1), immunoglobulin G subtype 4 was 4.04 g/L and antinuclear antibody was weakly positive. The white blood cells, neutrophils, lymphocytes, eosinophils and platelets were in normal range except for a slight decrease of red blood cells and hemoglobin level. The other tests including the vasculitis antibodies, fungal (1-3)-β-D glycan, and galaetomannan test were normal. Brain enhanced MRI on Dec.7 showed a new abnormal signal focus in the left occipital-parietal lobe, and the operation area of the right parietal lobe had more obvious effusion and edema . Lumbar puncture on Dec. 7 revealed high intracranial pressure (330 mmH2O), elevation in white cell count (320*106/L, neutrophils 45%, lymphocytes 55%) and protein (1041 mg/L), as well as a slight decrease in glucose (2.01 mmol/L) and chloride (116.1 mmol/L). No acid fast bacilli, fungi and bacteria were found in the cerebrospinal fluid (CSF) smear and culture. Despite a treatment with intravenous Ceftriaxone Sodium (2 g twice daily for 4 days), the patient still had an obvious headache, diplopia, non-fluent speech and worse muscle strength in his left limbs. Neurological examination on Dec. 10 showed left eyeball adduction, left eyeball abduction, and right eyeball abduction were impaired. Re-examination of lumbar puncture on Dec.11 showed that the CSF data were getting worse (intracranial pressure 330 mmH2O, white cell count 480*106/L with neutrophils 40%, lymphocytes 60% and protein 1422 mg/L, glucose 1.24 mmol/L and chloride 111.5 mmol/L). Intravenous Vancomycin (1.0 g iv drip Q12h) and Meropenem (0.5 g iv drip Q6h) were applied on Dec.11 due to consideration of intracranial infection caused by bacteria. High-throughput next-generation sequencing (Vision Medicals, Guangzhou) detected the presence of Balamuthia mandrillaris with 112 sequence copy reads in serum and 539 sequence copy reads in the CSF . GAE caused by Balamuthia mandrillaris was thus diagnosed. On Dec.14, the treatment was adjusted to compound treatment with sulfamethoxazole/trimethoprim 0.48 g×2 tablets po. Bid, azithromycin tablets 0.25 g×2 po. Qd, flucytosine 2.5 g iv drip Q12 h, and amphotericin B iv drip Qd (increased gradually with 5–10–15–20–25–30 mg). He did not receive a combination therapy of miltefosine and pentamidine because neither medication was available in China. The patient often went fishing in the past 10 years and worked occasionally in a paddy field. He had no known tick bites or any skin lesions.\nRe-examination of brain MRI on Dec. 23 showed larger lesions on the left cerebral hemisphere with enhancement, causing left subfalcine herniation . The patient was transferred to the department of neurosurgery and was re-operated on Dec. 27. Histological examination of the left occipital lobe confirmed amoebic trophozoite gathering around blood vessels under high magnification . The presence of B. mandrillaris with 3723 sequence copy reads was also detected in brain tissue via NGS . After surgery, re-examination of brain MRI on Jan. 6, 2021 indicated that the lesion and subfalcine herniation of the left cerebral hemisphere were relieved slightly than before . However, the patient developed progressive confusion. A repeated head CT on Jan. 13 revealed that the left subfalcine herniation became worse after medication therapy was discontinued for two weeks. A combined medication therapy was restarted with sulfamethoxazole/trimethoprim (0.48 g×2 po. Bid), azithromycin tablets (0.25 g×2 po. Qd), flucytosine (2.5 g iv drip q12h) and fluconazole (0.6 g iv drip Qd). After treatment, the patient felt better than before with a mild headache. ADL scores were 40 before and 45 after the second surgery. An additional head CT on Feb. 22 revealed that the left subfalcine herniation was slightly relieved . The patient was transferred to another local hospital on Feb. 22 for continuous treatment with sulfamethoxazole (po), azithromycin (po) and fluconazole (iv drip).\nThe patient responded favorably to the first surgery in part as showed in head CT and MRI ; the lesions of the right parietal lobe were obviously getting smaller. He responded well slightly to the second excision with the left occipital lobe lesions and the subfalcine herniation was getting better in head CT and MRI . It is interesting that calcification was seen in the left parietal lobe and basal ganglia after Dec. 18 , as well as the right parietal lobe after Feb. 10 .\nAt the follow-up by phone, the patient was discharged from the local hospital on April 2, 2021 and showed good recovery with a ADL score of 95, in comparison to past scores of 70 (before the first surgery) and 40 (before the second surgery) as shown in Table . At the follow-up by phone on June. 2, 2021, the patient has been taking with sulfamethoxazole (po) and azithromycin (po) and shows slow recovery with a current ADL score of 100 as shown in Table .", + "fulltext_subclaims": [ + "A 54-year-old male was admitted to the First Affiliated Hospital of Guangxi Medical University on Nov. 1, 2020.", + "The patient experienced acute onset of numbness and weakness in his left limb.", + "Initial MRI of the brain showed abnormal signals in the right parietal lobe.", + "Brain CT and enhanced MRI on Nov. 10 showed an ill-defined infiltrating enhanced mass in the right parietal lobe with perilesional edema.", + "The mass pointed to the possibility of a low-grade glioma.", + "Resection of the mass in the right parietal lobe was performed on Nov. 12.", + "The specimen exhibited granulomatous changes and inflammatory perivascular infiltrate with positive CD68 staining.", + "The specimen showed negative acid-fast, periodic acid-achiff, and CD235a staining.", + "The patient received intravenous Linezolid (0.2 g twice daily for 9 days).", + "The ADL score was 75 after the surgery.", + "The ADL score was 70 before the surgery.", + "The patient had a headache accompanied by diplopia and difficulty walking when taking hyperbaric oxygen therapy on Nov. 28.", + "An emergency head CT on Dec. 2 showed a new low-density focus in the left occipital lobe.", + "The blood tests on Dec. 5 revealed an erythrocyte sedimentation rate of 31 mm/h.", + "The hypersensitive C-reactive protein was 0.8 mg/L.", + "Immunoglobulin G subtype 4 was 4.04 g/L.", + "Antinuclear antibody was weakly positive.", + "The white blood cells, neutrophils, lymphocytes, eosinophils, and platelets were in normal range.", + "Red blood cells and hemoglobin level were slightly decreased.", + "The vasculitis antibodies, fungal (1-3)-β-D glycan, and galactomannan test were normal.", + "Brain enhanced MRI on Dec. 7 showed a new abnormal signal focus in the left occipital-parietal lobe.", + "The operation area of the right parietal lobe had more obvious effusion and edema.", + "Lumbar puncture on Dec. 7 revealed high intracranial pressure (330 mmH2O).", + "The CSF white cell count was 320*106/L with neutrophils 45% and lymphocytes 55%.", + "The CSF protein was 1041 mg/L.", + "The CSF glucose was 2.01 mmol/L.", + "The CSF chloride was 116.1 mmol/L.", + "No acid fast bacilli, fungi, or bacteria were found in the CSF smear and culture.", + "Intravenous Ceftriaxone Sodium (2 g twice daily for 4 days) was administered.", + "The patient still had an obvious headache, diplopia, non-fluent speech, and worse muscle strength in his left limbs.", + "Neurological examination on Dec. 10 showed impaired left eyeball adduction, left eyeball abduction, and right eyeball abduction.", + "Re-examination of lumbar puncture on Dec. 11 showed intracranial pressure of 330 mmH2O.", + "The CSF white cell count was 480*106/L with neutrophils 40% and lymphocytes 60%.", + "The CSF protein was 1422 mg/L.", + "The CSF glucose was 1.24 mmol/L.", + "The CSF chloride was 111.5 mmol/L.", + "Intravenous Vancomycin (1.0 g iv drip Q12h) and Meropenem (0.5 g iv drip Q6h) were applied on Dec. 11.", + "High-throughput next-generation sequencing detected Balamuthia mandrillaris with 112 sequence copy reads in serum.", + "Balamuthia mandrillaris was detected with 539 sequence copy reads in the CSF.", + "GAE caused by Balamuthia mandrillaris was diagnosed.", + "The treatment was adjusted to include sulfamethoxazole/trimethoprim 0.48 g×2 tablets po. Bid.", + "Azithromycin tablets 0.25 g×2 po. Qd were added.", + "Flucytosine 2.5 g iv drip Q12 h was administered.", + "Amphotericin B iv drip Qd was started, increased gradually from 5–10–15–20–25–30 mg.", + "The patient did not receive miltefosine and pentamidine because neither medication was available in China.", + "The patient often went fishing in the past 10 years.", + "The patient worked occasionally in a paddy field.", + "The patient had no known tick bites or any skin lesions.", + "Brain MRI on Dec. 23 showed larger lesions on the left cerebral hemisphere with enhancement.", + "The lesions caused left subfalcine herniation.", + "The patient was re-operated on Dec. 27.", + "Histological examination of the left occipital lobe confirmed amoebic trophozoite gathering around blood vessels.", + "B. mandrillaris with 3723 sequence copy reads was detected in brain tissue via NGS.", + "Brain MRI on Jan. 6, 2021 showed that the lesion and subfalcine herniation of the left cerebral hemisphere were slightly relieved.", + "The patient developed progressive confusion.", + "A repeated head CT on Jan. 13 revealed that the left subfalcine herniation became worse after medication therapy was discontinued for two weeks.", + "Combined medication therapy was restarted with sulfamethoxazole/trimethoprim (0.48 g×2 po. Bid), azithromycin tablets (0.25 g×2 po. Qd), flucytosine (2.5 g iv drip q12h), and fluconazole (0.6 g iv drip Qd).", + "After treatment, the patient felt better than before with a mild headache.", + "The ADL score was 40 before the second surgery.", + "The ADL score was 45 after the second surgery.", + "An additional head CT on Feb. 22 revealed that the left subfalcine herniation was slightly relieved.", + "The patient was transferred to another local hospital on Feb. 22.", + "The patient was discharged from the local hospital on April 2, 2021.", + "The patient showed good recovery with an ADL score of 95.", + "At the follow-up by phone on June 2, 2021, the patient has been taking sulfamethoxazole (po) and azithromycin (po).", + "The patient shows slow recovery with a current ADL score of 100." + ], + "summary": "A 54-year-old male was admitted to hospital after experiencing acute onset of numbness and weakness on his left limb. Due to the initial consideration of intracranial tumor, surgical removal of the right parietal lesion was performed. However, the patient had a headache accompanied by diplopia, difficulty walking and a new lesion was found in the left occipital-parietal lobe two weeks after the first operation. High-throughput next-generation sequencing (NGS) detected the presence of high copy reads of the B. mandrillaris genome sequence in the patient's blood, cerebral spinal fluid (CSF), and brain tissue. Pathological investigation of the brain tissue showed granulomatous changes and amoebic trophozoite scattered around blood vessels under high magnification. The patient was re-operated due to developing progressive confusion caused by subfalcine herniation of the left cerebral hemisphere. The lesions of the right parietal lobe were obviously decreasing in size after the first surgery, and the lesions of the left occipital lobe and the sunfalcine herniation didn't ameliorate two months after the second surgery. The patient was transferred to local hospital for continuous treatment with sulfamethoxazole and azithromycin. After five months of the second surgery, the patient showed good recovery with mild headache.", + "summary_subclaims": [ + "A 54-year-old male was admitted to hospital after experiencing acute onset of numbness and weakness on his left limb.", + "Surgical removal of the right parietal lesion was performed.", + "The patient had a headache accompanied by diplopia.", + "A new lesion was found in the left occipital-parietal lobe two weeks after the first operation.", + "High-throughput next-generation sequencing detected the presence of high copy reads of the B. mandrillaris genome sequence in the patient's blood.", + "High-throughput next-generation sequencing detected the presence of high copy reads of the B. mandrillaris genome sequence in the patient's cerebral spinal fluid.", + "High-throughput next-generation sequencing detected the presence of high copy reads of the B. mandrillaris genome sequence in the patient's brain tissue.", + "Pathological investigation of the brain tissue showed granulomatous changes.", + "Pathological investigation of the brain tissue showed amoebic trophozoite scattered around blood vessels under high magnification.", + "The patient was re-operated due to developing progressive confusion caused by subfalcine herniation of the left cerebral hemisphere.", + "The lesions of the right parietal lobe were obviously decreasing in size after the first surgery.", + "The lesions of the left occipital lobe and the subfalcine herniation didn't ameliorate two months after the second surgery.", + "The patient was transferred to local hospital for continuous treatment with sulfamethoxazole and azithromycin.", + "After five months of the second surgery, the patient showed good recovery with mild headache." + ] + }, + { + "id": "multiclinsum_test_4_en.txt", + "fulltext": "A 54-year-old woman was referred to us by the Department of Plastic and Reconstructive Surgery in our medical center for further evaluation of prolonged right nipple erosion. She had previously received a diagnosis of right breast cancer and undergone total mastectomy and axillary dissection 15 years ago in another hospital. Histopathology identified an invasive ductal carcinoma with a tumor diameter of 0.9 cm and a nuclear grade of 2; one of 23 lymph nodes showed metastasis. Tissue profiling revealed the following: estrogen receptor (ER), positive; progesterone receptor (PgR), negative; and human epidermal growth factor receptor 2 (HER2), undetermined. As adjuvant therapy, she received six cycles of cyclophosphamide, methotrexate, and 5-fluorouracil (CMF), followed by tamoxifen for 3.5 years. Then, she defaulted her endocrine therapy. Seven years after the surgery, the doctors from our medical center performed ABR with a deep inferior epigastric perforator (DIEP) flap at another facility. The following year, her right nipple was reconstructed by V-shaped resection of the left nipple and an autologous grafting/nipple-sharing technique. The right areola was reconstructed with a penetrating skin graft from the proximal thigh and left areola. Concurrent mastopexy was performed for the left breast .\nAfter 7.5 years, right nipple erosion appeared, and she visited the Department of Plastic and Reconstructive Surgery in our medical center. At first, it appeared that she had an eczematous nipple lesion caused by an infection, and she was treated with antibiotics; however, the erosion progressed and enlarged over the course of a few months. She was eventually referred to our department. The skin on the right side of her chest around the NAC and the subcutaneous adipose tissue consisted of transferred tissue from her abdomen, as the DIEP flap and grafted nipple were constructed on the skin graft. In the right nipple, normal tissue was almost completely affected by erosion, and there was no abnormality, itching, or pain in the right areola . Scrape cytology revealed malignancy of the epithelial cells, and that the right nipple carcinoma originated from the tissue taken from the left nipple. On magnetic resonance imaging (MRI), the malignant lesion seemed limited to the area around the grafted right nipple , with no malignancy observed in the left breast on MRI and computed tomography (CT) . In addition, no distant metastases were observed on CT. Paget’s disease was clinically suspected, and we performed surgical treatment. Though the standard surgical operation for mammary Paget’s disease is mastectomy, we performed partial breast excision including the right nipple with sufficient lateral and deep margins because there was no mammary tissue in the right reconstructed breast, except for the nipple and areola. The incision was closed with investing sutures.\nThe specimen submitted for surgical pathology was composed of epithelial and adipose tissue grafted from the abdomen, areolar tissue grafted from the base of the thigh and left areola, and a nipple graft from the contralateral side. Macroscopically, the lesion spread around the nipple and adipose tissue . Pathological examination identified invasive ductal carcinoma with a few comedo ductal components within the nipple, extensive infiltration of grafted epithelial and adipose tissue , and a tumor diameter of 25 mm. The nuclear grade score was 2 (nuclear atypia score was 2 and mitotic count score was 2), there was no lymphatic or vascular invasion, and the lateral and deep margins were negative. Immunohistochemical staining showed strong positive for ER, weak positive for PgR, positive for HER2 with a score of 3+, and 35% cells showing positive Ki-67 staining.\nAs the biological profile classified the tumor as a luminal HER2 type, weekly paclitaxel, trastuzumab, and endocrine therapy were administered as adjuvant therapies. No distant metastases or local recurrence were seen 1 year after the surgery.", + "fulltext_subclaims": [ + "The patient is a 54-year-old woman.", + "She was referred to the Department of Plastic and Reconstructive Surgery for prolonged right nipple erosion.", + "She had previously received a diagnosis of right breast cancer.", + "She underwent total mastectomy and axillary dissection 15 years ago.", + "Histopathology identified an invasive ductal carcinoma with a tumor diameter of 0.9 cm.", + "The nuclear grade was 2.", + "One of 23 lymph nodes showed metastasis.", + "Estrogen receptor (ER) was positive.", + "Progesterone receptor (PgR) was negative.", + "Human epidermal growth factor receptor 2 (HER2) was undetermined.", + "She received six cycles of cyclophosphamide, methotrexate, and 5-fluorouracil (CMF).", + "She received tamoxifen for 3.5 years.", + "She defaulted her endocrine therapy.", + "Seven years after the surgery, she had ABR with a deep inferior epigastric perforator (DIEP) flap.", + "The right areola was reconstructed with a penetrating skin graft from the proximal thigh and left areola.", + "Right nipple erosion appeared 7.5 years after the surgery.", + "She was initially treated with antibiotics.", + "The erosion progressed and enlarged over the course of a few months.", + "The right nipple carcinoma originated from the tissue taken from the left nipple.", + "On MRI, the malignant lesion seemed limited to the area around the grafted right nipple.", + "No malignancy was observed in the left breast on MRI and CT.", + "No distant metastases were observed on CT.", + "Paget’s disease was clinically suspected.", + "Partial breast excision including the right nipple with sufficient lateral and deep margins was performed.", + "The specimen submitted for surgical pathology was composed of epithelial and adipose tissue grafted from the abdomen, areolar tissue grafted from the base of the thigh and left areola, and a nipple graft from the contralateral side.", + "Pathological examination identified invasive ductal carcinoma with a few comedo ductal components within the nipple.", + "The tumor diameter was 25 mm.", + "The nuclear grade score was 2.", + "There was no lymphatic or vascular invasion.", + "The lateral and deep margins were negative.", + "Immunohistochemical staining showed strong positive for ER.", + "Immunohistochemical staining showed weak positive for PgR.", + "Immunohistochemical staining showed positive for HER2 with a score of 3+.", + "35% cells showed positive Ki-67 staining.", + "Weekly paclitaxel, trastuzumab, and endocrine therapy were administered as adjuvant therapies.", + "No distant metastases or local recurrence were seen 1 year after the surgery." + ], + "summary": "A 54-year-old woman was referred to us by the Department of Plastic and Reconstructive Surgery in our medical center for further evaluation of right nipple erosion. She had undergone total mastectomy of the right breast following a breast cancer diagnosis 15 years ago, at which time tumor biological profiling revealed the following: estrogen receptor (ER), positive; progesterone receptor (PgR), negative; and human epidermal growth factor receptor 2 (HER2), undetermined. She received adjuvant chemotherapy and endocrine therapy. She defaulted endocrine therapy for a few years, and 7 years after surgery, she underwent autologous breast reconstruction with a deep inferior epigastric perforator (DIEP) flap. In the following year, NAC reconstruction was performed using a composite graft technique. Seven years after the NAC reconstruction, erosion appeared on the nipple grafted from its contralateral counterpart; scrape cytology revealed malignancy. The skin on the right side of her chest around the NAC and subcutaneous fat tissue consisted of transferred tissue from the abdomen, as the DIEP flap and grafted nipple were located on the graft skin. The right nipple carcinoma arose from the tissue taken from the left nipple. Magnetic resonance imaging (MRI) or computed tomography showed no malignant findings in the left breast. As the malignant lesion seemed limited to the area around the grafted right nipple on MRI, surgical resection with sufficient lateral and deep margins was performed around the right nipple. Pathological findings revealed invasive ductal carcinoma with comedo ductal components infiltrating the graft skin and underlying adipose tissue. Immunohistochemistry revealed positive for ER, PgR, and HER2.", + "summary_subclaims": [ + "A 54-year-old woman was referred to us by the Department of Plastic and Reconstructive Surgery in our medical center for further evaluation of right nipple erosion.", + "She had undergone total mastectomy of the right breast following a breast cancer diagnosis 15 years ago.", + "Tumor biological profiling revealed estrogen receptor (ER), positive.", + "Tumor biological profiling revealed progesterone receptor (PgR), negative.", + "Tumor biological profiling revealed human epidermal growth factor receptor 2 (HER2), undetermined.", + "She received adjuvant chemotherapy and endocrine therapy.", + "She defaulted endocrine therapy for a few years.", + "Seven years after surgery, she underwent autologous breast reconstruction with a deep inferior epigastric perforator (DIEP) flap.", + "In the following year, NAC reconstruction was performed using a composite graft technique.", + "Seven years after the NAC reconstruction, erosion appeared on the nipple grafted from its contralateral counterpart.", + "Scrape cytology revealed malignancy.", + "The skin on the right side of her chest around the NAC and subcutaneous fat tissue consisted of transferred tissue from the abdomen.", + "The right nipple carcinoma arose from the tissue taken from the left nipple.", + "Magnetic resonance imaging (MRI) or computed tomography showed no malignant findings in the left breast.", + "As the malignant lesion seemed limited to the area around the grafted right nipple on MRI, surgical resection with sufficient lateral and deep margins was performed around the right nipple.", + "Pathological findings revealed invasive ductal carcinoma with comedo ductal components infiltrating the graft skin and underlying adipose tissue.", + "Immunohistochemistry revealed positive for ER.", + "Immunohistochemistry revealed positive for PgR.", + "Immunohistochemistry revealed positive for HER2." + ] + }, + { + "id": "multiclinsum_test_3044_en.txt", + "fulltext": "A 41-year-old woman diagnosed with multiple sclerosis in 2011 and treated with mirtazapine 15 mg daily and quetiapine 50 mg daily for mood disorders.\n\nIn July 2021, he started treatment with DMF and reported nausea and abdominal pain as adverse effects. A week later, while taking 240 mg of DMF daily, he reported pruritus in the right upper extremity, followed by the appearance of erythematous areas with vesicles. He presented for consultation a week later, when the skin lesions had spread to the right lower extremity. He did not have fever or systemic symptoms. Treatment with DMF was discontinued and a blood test and biopsy of the lesions were performed. The blood count showed an elevation of the eosinophil count to 2,000 uL. The pathological study showed an eosinophil infiltrate at the dermis level compatible with Wells syndrome. The clinical evolution was favorable, with the resolution of the lesions and the normalization of the eosinophilia in approximately four weeks. It was not necessary to administer corticosteroids.\n", + "fulltext_subclaims": [ + "The patient is a 41-year-old woman.", + "She was diagnosed with multiple sclerosis in 2011.", + "She was treated with mirtazapine 15 mg daily.", + "She was treated with quetiapine 50 mg daily.", + "In July 2021, he started treatment with DMF.", + "He reported nausea and abdominal pain as adverse effects.", + "A week later, while taking 240 mg of DMF daily, he reported pruritus in the right upper extremity.", + "He reported the appearance of erythematous areas with vesicles.", + "He presented for consultation a week later.", + "The skin lesions had spread to the right lower extremity.", + "He did not have fever or systemic symptoms.", + "Treatment with DMF was discontinued.", + "A blood test and biopsy of the lesions were performed.", + "The blood count showed an elevation of the eosinophil count to 2,000 uL.", + "The pathological study showed an eosinophil infiltrate at the dermis level.", + "The pathological study was compatible with Wells syndrome.", + "The clinical evolution was favorable.", + "The lesions resolved in approximately four weeks.", + "The eosinophilia normalized in approximately four weeks.", + "It was not necessary to administer corticosteroids." + ], + "summary": "41-year-old woman who started treatment with DMF in July 2021. One week later, she began to have pruritus in the right extremities, followed by the appearance of erythematous areas with vesicles. The blood count showed an elevation of the eosinophil count to 2,000 µL. The pathological anatomical study showed an eosinophil infiltrate at the dermis level compatible with Wells syndrome. The clinical evolution was favorable, with resolution of the lesions and normalization of the eosinophilia in approximately four weeks. It was not necessary to administer corticosteroids.\n", + "summary_subclaims": [ + "The patient is a 41-year-old woman.", + "She started treatment with DMF in July 2021.", + "One week later, she began to have pruritus in the right extremities.", + "Erythematous areas with vesicles appeared.", + "The blood count showed an elevation of the eosinophil count to 2,000 µL.", + "The pathological anatomical study showed an eosinophil infiltrate at the dermis level.", + "The findings were compatible with Wells syndrome.", + "The clinical evolution was favorable.", + "The lesions resolved in approximately four weeks.", + "The eosinophilia normalized in approximately four weeks.", + "It was not necessary to administer corticosteroids." + ] + }, + { + "id": "multiclinsum_test_1361_en.txt", + "fulltext": "The patient was a 79-year-old man with a history of methicillin-resistant Staphylococcus aureus infection (acquired during brain surgery), mitral regurgitation (MR), chronic atrial fibrillation for 9 years, and decreased left ventricular contractility.\nHe had eight long-term hospitalizations during which he underwent multiple operations. Metal allergies to nickel (Ni) and cobalt (Co) were detected 8 years prior. The MR gradually worsened and became more severe. Dyspnoea on exertion appeared approximately 2 years prior and gradually worsened.\nOne year prior, he was hospitalized for heart failure. Soon after discharge, he gained weight and experienced dyspnoea on exertion, accompanied by lower-leg oedema. Echocardiography showed severe MR, reduced ejection fraction (EF, 50%), and deterioration of pulmonary hypertension (pulmonary pressure: 37/16/25 mmHg).\nBecause of recurrent heart failure, an elective surgery was planned after the previous hospital admission, following the successful management of heart failure. Preoperative echocardiography showed the following: left ventricular internal end-diastolic (LVEDD) and end-systolic diameters (LVESD) of 68 and 48 mm, respectively—EF of 45%, severe MR with central jet (tenting height, 12 mm) ( and ), moderate tricuspid regurgitation (TR) (tenting height, 8 mm) , a left atrial diameter of 66 mm, and progressive MR with increased diuretics. Using coronary angiogram and technetium-99m, cardiologists ruled out ischaemia and amyloidosis as the cause of LV dysfunction. Although the LV size was large, the LVEF was over 40% and the wall thickness was approximately 13 mm. Therefore, it was not a typical dilated cardiomyopathy (DCM); yet DCM could not be excluded as the cause of LV dysfunction.\nProsthetic valves, rings, and TEER containing Ni and Co were contraindicated. Additionally, the sternal closure required a Ni- and Co-free sternal wire. We selected Ni- and Co-free rings for mitral and tricuspid annuloplasty. We used titanium wire for sternal closure as stainless steel can contain traces of nickel. Cardiopulmonary bypass was established through median sternotomy using standard aortic and bicaval cannulation. Antegrade blood cardioplegia was administered, and the left atrium was accessed via a transseptal approach.\nNo chord rupture was observed. Left atrial ablation was performed using a modified maze procedure with cryoablation. The left atrial appendage was then resected. A 28-mm Ni- and Co-free Séguin Ring (Séguin Semi-Rigid Annuloplasty Ring; Abbot Medical, Austin, TX, USA) was chosen for mitral valve repair. After the annular mattress sutures were tied, they were passed around the annuloplasty ring again, taking additional bites of atrial tissue and tied again (the double-suture technique). The tricuspid valve was examined after the closure of the interatrial septum. The diameter of the annulus was 55 mm. In addition to annulus enlargement, tethering was also contributing to regurgitation.\nSubsequently, a pledgeted CV4 suture (GORE-TEX® Suture; W. L. Gore & Associates Inc., Newark, DE, USA) was placed at the base of the anterior papillary muscle (PM) and continuously sutured clockwise to the base of the secondary and then inferior PM. The CV4 suture crossed the interventricular septum and externalized the septal ring of the right atrium. After tricuspid annuloplasty using a 27-mm Ni- and Co-free ring (Duran Flexible Partial Ring; Medtronic Inc., Minneapolis, MN, USA) the CV4 suture was passed through the ring. Suture length adjustments were performed under a water test, and the sutures were tied (spiral suspension technique).\nNext, a pledgeted CV4 suture was passed through the head of the anterior and posterior PM via an aortotomy. It was passed from the left ventricular cavity through the mid-septal fibrous annulus and exteriorized through the aortic wall beneath the commissure between the non-coronary and left coronary aortic cusps (PM repositioning) ( and ). Aortotomy was closed with two layers of continuous sutures, and the sternum was closed with a pure titanium wire (Yokozuna wire; USCI Holdings, Tokyo, Japan). Transoesophageal echocardiography confirmed that the MR and TR had disappeared. Postoperative transthoracic echography revealed a trivial MR (tenting height, 8 mm) and disappearance of TR.\nAfter undergoing treatment for heart failure in the cardiology department, the patient was discharged from the hospital on the 26th postoperative day without dialysis intervention. Two years after surgery, MR and TR had not worsened on echocardiography .", + "fulltext_subclaims": [ + "The patient was a 79-year-old man.", + "He had a history of methicillin-resistant Staphylococcus aureus infection acquired during brain surgery.", + "He had mitral regurgitation.", + "He had chronic atrial fibrillation for 9 years.", + "He had decreased left ventricular contractility.", + "He had eight long-term hospitalizations.", + "He underwent multiple operations.", + "Metal allergies to nickel and cobalt were detected 8 years prior.", + "The MR gradually worsened and became more severe.", + "Dyspnoea on exertion appeared approximately 2 years prior.", + "He was hospitalized for heart failure one year prior.", + "Soon after discharge, he gained weight.", + "Soon after discharge, he experienced dyspnoea on exertion.", + "Soon after discharge, he had lower-leg oedema.", + "Echocardiography showed severe MR.", + "Echocardiography showed reduced ejection fraction of 50%.", + "Echocardiography showed deterioration of pulmonary hypertension.", + "Pulmonary pressure was 37/16/25 mmHg.", + "An elective surgery was planned after the previous hospital admission.", + "Preoperative echocardiography showed LVEDD of 68 mm.", + "Preoperative echocardiography showed LVESD of 48 mm.", + "Preoperative echocardiography showed EF of 45%.", + "Preoperative echocardiography showed severe MR with central jet.", + "Preoperative echocardiography showed tenting height of 12 mm.", + "Preoperative echocardiography showed moderate tricuspid regurgitation.", + "Preoperative echocardiography showed tenting height of 8 mm.", + "Preoperative echocardiography showed left atrial diameter of 66 mm.", + "Preoperative echocardiography showed progressive MR with increased diuretics.", + "Cardiologists ruled out ischaemia as the cause of LV dysfunction.", + "Cardiologists ruled out amyloidosis as the cause of LV dysfunction.", + "The LV size was large.", + "The LVEF was over 40%.", + "The wall thickness was approximately 13 mm.", + "It was not a typical dilated cardiomyopathy.", + "Dilated cardiomyopathy could not be excluded as the cause of LV dysfunction.", + "Prosthetic valves, rings, and TEER containing Ni and Co were contraindicated.", + "The sternal closure required a Ni- and Co-free sternal wire.", + "Ni- and Co-free rings were selected for mitral and tricuspid annuloplasty.", + "Titanium wire was used for sternal closure.", + "Cardiopulmonary bypass was established through median sternotomy.", + "Antegrade blood cardioplegia was administered.", + "The left atrium was accessed via a transseptal approach.", + "No chord rupture was observed.", + "Left atrial ablation was performed using a modified maze procedure with cryoablation.", + "The left atrial appendage was resected.", + "A 28-mm Ni- and Co-free Séguin Ring was chosen for mitral valve repair.", + "The double-suture technique was used.", + "The tricuspid valve was examined after the closure of the interatrial septum.", + "The diameter of the annulus was 55 mm.", + "A pledgeted CV4 suture was placed at the base of the anterior papillary muscle.", + "The CV4 suture was continuously sutured clockwise to the base of the secondary and then inferior PM.", + "The CV4 suture crossed the interventricular septum.", + "The CV4 suture was externalized through the septal ring of the right atrium.", + "Tricuspid annuloplasty used a 27-mm Ni- and Co-free ring.", + "Suture length adjustments were performed under a water test.", + "The sutures were tied using the spiral suspension technique.", + "A pledgeted CV4 suture was passed through the head of the anterior and posterior PM via an aortotomy.", + "The suture was passed from the left ventricular cavity through the mid-septal fibrous annulus.", + "The suture was exteriorized through the aortic wall beneath the commissure between the non-coronary and left coronary aortic cusps.", + "Aortotomy was closed with two layers of continuous sutures.", + "The sternum was closed with a pure titanium wire.", + "Transoesophageal echocardiography confirmed that MR and TR had disappeared.", + "Postoperative transthoracic echography revealed trivial MR.", + "Postoperative transthoracic echography showed tenting height of 8 mm.", + "Postoperative transthoracic echography showed disappearance of TR.", + "The patient was discharged from the hospital on the 26th postoperative day.", + "Two years after surgery, MR and TR had not worsened on echocardiography." + ], + "summary": "We report the case of a 79-year-old man with severe functional mitral regurgitation (Type IIIb) and a history of nickel and cobalt allergies. We safely performed mitral valve repair with papillary muscle repositioning with nickel- and cobalt-free rings in this patient. He was discharged from the hospital on the 26th postoperative day without dialysis intervention. Two years after surgery, mitral and tricuspid regurgitation had not worsened.", + "summary_subclaims": [ + "The patient was a 79-year-old man.", + "The patient had severe functional mitral regurgitation (Type IIIb).", + "The patient had a history of nickel allergy.", + "The patient had a history of cobalt allergy.", + "Mitral valve repair with papillary muscle repositioning was performed.", + "Nickel- and cobalt-free rings were used for the repair.", + "The patient was discharged on the 26th postoperative day.", + "The patient did not receive dialysis intervention.", + "Two years after surgery, mitral regurgitation had not worsened.", + "Two years after surgery, tricuspid regurgitation had not worsened." + ] + }, + { + "id": "multiclinsum_test_2580_en.txt", + "fulltext": "A 54-year-old Thai man presented with low back pain lasting for 2 months. The symptom was gradually progressive and was aggravated by movements. The pain was referred to both legs and did not improve with medications. Later, the patient experienced weakness and numbness in his right leg and had walking difficulties. In addition, he had urinary retention which required urinary catheterization. The patient's symptoms worsened and limited his daily activities. Examination revealed generalized erythematous plaques on his head, trunk, back, and extremities. He also had several flaccid blisters. The patient had grade III motor weakness and paresthesia in his entire right leg; however, there was minimal motor weakness on the left side. Sacral sensation and sphincter tone were intact. Magnetic resonance imaging (MRI) of the lumbar spine showed a pattern of arachnoiditis at the L1-5 level. There were also multiple hypersignal intensity bead-like lesions on T2-weighted images in the spinal canal of the L4-5 vertebral level. The lesions were not enhanced with contrast . Laminectomy in the L4-5 with lesionectomy was performed because we considered a spinal infection resulting in the recent neurological deficits. During surgery, we observed that the nerve roots were severely clumped together and had arachnoid adhesion. The lesions were found to be multiple tapeworms between the nerve roots and were completely removed with partial lysis of the adhesions under nerve root monitoring . Microscopic examination demonstrated the presence of spargana with thick outer eosinophilic teguments and inner calcospherites . Therefore, spinal sparganosis was diagnosed.\nThe patient was a monk on pilgrimage and had ingested uncooked frogs, snakes, and other amphibians for 10 years. The year prior to his visit he was diagnosed with bullous pemphigoid and was on high-dose prednisolone since then. Further investigation was done to rule out potentially disseminated sparganosis. In addition, the patient had a history of epilepsy, which was neither investigated nor treated. Although brain MRI indicated cerebral atrophy with surrounding hypersignal intensity in the left parieto-occipital area on T2-weighted images, which is compatible with old inflammation, there was no evidence of the live parasite in the brain . An ocular examination by an ophthalmologist indicated the presence of an abnormal cystic, worm-like mass with calcification in the right conjunctiva. This was considered a nonactive lesion. However, we did not perform an enzyme-linked immunosorbent assay (ELISA) for sparganum or a cerebrospinal fluid (CSF) study. A stool examination revealed no evidence of parasite infection.\nIn the early postoperative period, the patient still had severe back pain; however, this improved during follow-up after a few months. Radicular pain, and weakness were also improved; however, neurological function of the urinary bladder was still deficit.", + "fulltext_subclaims": [ + "The patient is a 54-year-old Thai man.", + "He had low back pain lasting for 2 months.", + "The back pain was gradually progressive.", + "The back pain was aggravated by movements.", + "The pain was referred to both legs.", + "The pain did not improve with medications.", + "The patient experienced weakness and numbness in his right leg.", + "He had walking difficulties.", + "He had urinary retention requiring urinary catheterization.", + "The patient's symptoms worsened and limited his daily activities.", + "Examination revealed generalized erythematous plaques on his head, trunk, back, and extremities.", + "He had several flaccid blisters.", + "He had grade III motor weakness and paresthesia in his entire right leg.", + "There was minimal motor weakness on the left side.", + "Sacral sensation and sphincter tone were intact.", + "MRI of the lumbar spine showed a pattern of arachnoiditis at the L1-5 level.", + "There were multiple hypersignal intensity bead-like lesions on T2-weighted images in the spinal canal of the L4-5 vertebral level.", + "The lesions were not enhanced with contrast.", + "Laminectomy in the L4-5 with lesionectomy was performed.", + "During surgery, the nerve roots were severely clumped together and had arachnoid adhesion.", + "The lesions were found to be multiple tapeworms between the nerve roots.", + "The tapeworms were completely removed with partial lysis of the adhesions under nerve root monitoring.", + "Microscopic examination demonstrated the presence of spargana with thick outer eosinophilic teguments and inner calcospherites.", + "Spinal sparganosis was diagnosed.", + "The patient had ingested uncooked frogs, snakes, and other amphibians for 10 years.", + "The year prior to his visit, he was diagnosed with bullous pemphigoid.", + "He was on high-dose prednisolone since the diagnosis of bullous pemphigoid.", + "Further investigation was done to rule out potentially disseminated sparganosis.", + "The patient had a history of epilepsy, which was neither investigated nor treated.", + "Brain MRI indicated cerebral atrophy with surrounding hypersignal intensity in the left parieto-occipital area on T2-weighted images.", + "There was no evidence of the live parasite in the brain.", + "An ocular examination indicated the presence of an abnormal cystic, worm-like mass with calcification in the right conjunctiva.", + "The ocular lesion was considered a nonactive lesion.", + "An enzyme-linked immunosorbent assay (ELISA) for sparganum was not performed.", + "A cerebrospinal fluid (CSF) study was not performed.", + "A stool examination revealed no evidence of parasite infection.", + "In the early postoperative period, the patient still had severe back pain.", + "The back pain improved during follow-up after a few months.", + "Radicular pain and weakness were also improved.", + "Neurological function of the urinary bladder was still deficit." + ], + "summary": "A 54-year-old man presented with progressive low back pain and neurological deficit at the lumbosacral level for 2 months. Imaging indicated arachnoiditis and an abnormal lesion at the L4-5 vertebral level. The patient underwent laminectomy of the L4-5 with lesionectomy and lysis of adhesions between the nerve roots. Microscopic examination indicated sparganum infection. Further brain imaging revealed evidence of chronic inflammation in the left parieto-occipital area without evidence of live parasites. In addition, an ophthalmologist reported a nonactive lesion in the right conjunctiva. The patient recovered well after surgery, although he had residual back pain and bladder dysfunction probably due to severe adhesion of the lumbosacral nerve roots.", + "summary_subclaims": [ + "The patient is a 54-year-old man.", + "He had progressive low back pain for 2 months.", + "He had a neurological deficit at the lumbosacral level.", + "Imaging indicated arachnoiditis.", + "Imaging showed an abnormal lesion at the L4-5 vertebral level.", + "The patient underwent laminectomy of the L4-5.", + "The patient had lesionectomy.", + "The patient had lysis of adhesions between the nerve roots.", + "Microscopic examination indicated sparganum infection.", + "Brain imaging revealed evidence of chronic inflammation in the left parieto-occipital area.", + "Brain imaging showed no evidence of live parasites.", + "An ophthalmologist reported a nonactive lesion in the right conjunctiva.", + "The patient recovered well after surgery.", + "He had residual back pain.", + "He had bladder dysfunction probably due to severe adhesion of the lumbosacral nerve roots." + ] + }, + { + "id": "multiclinsum_test_721_en.txt", + "fulltext": "A 71-year-old male patient was admitted to our hospital with pneumonia, and chronic diseases such as Parkinson’s disease, Alzheimer’s disease, lacunar cerebral infarction, and cardiac insufficiency. He had a 15-year history of hypertension and 5-year history of prostatic hyperplasia with stones. The day before admission, the patient’s body temperature rose to 37.6 ℃, with elevated neutrophils and high-sensitivity C-reactive protein (hs-CRP). Physical examination showed crackles in the lungs. Computer tomography (CT) scan showed multiple inflammations in both lungs, suggesting a pulmonary infection. Coagulation tests were normal (PT: 13.9 s, APTT: 30.2 s) . Biochemical tests showed increased urea, 7.29 (normal, 3.60–9.50) mmol/L, B-type brain natriuretic peptide BNP, 1050.0 (normal, 0.0-100.0) ng/L, creatine kinase CK, 172 (normal, 55–170) U/L, its isoenzyme CK-MB, 9.3 (normal, 0.0–24.0) U/L and cardiac troponin I cTnI, 0.575 (normal, 0.000-0.034) ng/ml. Therefore, the patient was treated with piperacillin/tazobactam (4.5 g three times daily, intravenous infusion), as well as symptomatic treatment including reducing phlegm, diuresis and control of Parkinson’s disease symptoms. In addition, Metoprolol and 4100 IU low-molecular-weight heparin were given to control the heart rate and prevent cerebrovascular accidents. Due to dysphagia, a gastric tube was inserted to improve his nutritional status.\nThe patient was unable to cough up sputum spontaneously on day 3 after admission and developed a high fever (38.6 ℃), so piperacillin/tazobactam was switched to meropenem (1.0 g three times daily, intravenous infusion) to intensify anti-infective therapy. However, sputum and blood culture results were negative. On day 11 after admission, the patient’s temperature dropped to normal, then meropenem was switched to cefmetazole (2.0 g twice daily, intravenous infusion). On day 15 after admission, the patient again developed fever (38.4 ℃), which was considered to be aspiration pneumonia probably due to prolonged bed rest and neurological disease. On day 18 after admission, the serum potassium value rose to 6.11 (normal 3.50–5.30) mmol/L. Calcium gluconate was used to antagonize potassium toxicity, along with high glucose plus insulin, furosemide, and potassium-free nutrient solution. In view of poor infection control and renal insufficiency, cefmetazole was again switched to meropenem (1.0 g once daily, intravenous infusion) on day 19 after admission.\nThe patient presented with severe coagulation abnormalities on day 20 after admission . Coagulation tests showed greatly prolonged PT (136.1s) and APTT (54.8s). However, the patient had a normal platelet count, no bleeding symptoms, and had not taken warfarin or other anticoagulant drugs. The results of the mixing study then showed a significantly lower PT (16s) , indicating the lack or anergy of coagulation factors. On day 21 after admission, 20 mg of vitamin K supplementation rescued the coagulation dysfunction . A chest CT showed obvious resorption of the infection lesions of bilateral lungs, so meropenem was replaced with cefodizime (2.0 g twice daily, intravenous infusion) to continue anti-infective therapy. The laboratory results of coagulation function returned to normal on day 22 after admission . In the following days, the pneumonia improved significantly, and the patient was discharged on day 33 after admission.", + "fulltext_subclaims": [ + "The patient was a 71-year-old male.", + "The patient was admitted with pneumonia.", + "The patient had chronic diseases such as Parkinson’s disease, Alzheimer’s disease, lacunar cerebral infarction, and cardiac insufficiency.", + "The patient had a 15-year history of hypertension.", + "The patient had a 5-year history of prostatic hyperplasia with stones.", + "The day before admission, the patient’s body temperature rose to 37.6 ℃.", + "Physical examination showed crackles in the lungs.", + "Computer tomography (CT) scan showed multiple inflammations in both lungs.", + "Coagulation tests were normal (PT: 13.9 s, APTT: 30.2 s).", + "Biochemical tests showed increased urea, 7.29 mmol/L.", + "Biochemical tests showed B-type brain natriuretic peptide BNP, 1050.0 ng/L.", + "Biochemical tests showed creatine kinase CK, 172 U/L.", + "Biochemical tests showed cardiac troponin I cTnI, 0.575 ng/ml.", + "The patient was treated with piperacillin/tazobactam (4.5 g three times daily, intravenous infusion).", + "The patient was given Metoprolol and 4100 IU low-molecular-weight heparin.", + "A gastric tube was inserted due to dysphagia.", + "On day 3 after admission, the patient was unable to cough up sputum spontaneously.", + "On day 3 after admission, the patient developed a high fever (38.6 ℃).", + "Piperacillin/tazobactam was switched to meropenem (1.0 g three times daily, intravenous infusion).", + "Sputum and blood culture results were negative.", + "On day 11 after admission, the patient’s temperature dropped to normal.", + "On day 11 after admission, meropenem was switched to cefmetazole (2.0 g twice daily, intravenous infusion).", + "On day 15 after admission, the patient again developed fever (38.4 ℃).", + "On day 18 after admission, the serum potassium value rose to 6.11 mmol/L.", + "Calcium gluconate was used to antagonize potassium toxicity.", + "Cefmetazole was again switched to meropenem (1.0 g once daily, intravenous infusion) on day 19 after admission.", + "The patient presented with severe coagulation abnormalities on day 20 after admission.", + "Coagulation tests showed greatly prolonged PT (136.1s) and APTT (54.8s).", + "The patient had a normal platelet count.", + "The patient had not taken warfarin or other anticoagulant drugs.", + "The results of the mixing study showed a significantly lower PT (16s).", + "On day 21 after admission, 20 mg of vitamin K supplementation rescued the coagulation dysfunction.", + "A chest CT showed obvious resorption of the infection lesions of bilateral lungs.", + "Meropenem was replaced with cefodizime (2.0 g twice daily, intravenous infusion).", + "The laboratory results of coagulation function returned to normal on day 22 after admission.", + "The patient was discharged on day 33 after admission." + ], + "summary": "We report a case of a 71-year-old male suffering from pulmonary infection with severe coagulation disorder without bleeding symptoms. He also had a history of Parkinson's disease, Alzheimer's disease and cardiac insufficiency. Coagulation tests were normal at the time of admission, prothrombin time (PT) is 13.9 (normal, 9.5-13.1) seconds and the activated partial thromboplastin time (APTT) is 30.2 (normal, 25.1-36.5) seconds. But it turned severely abnormal after 20 days (PT: 136.1 s, APTT: 54.8 s). However, no anticoagulants such as warfarin was used and no bleeding symptoms were observed. Subsequent mixing studies with normal plasma showed a decrease in prothrombin times. Vitamin K deficiency was thought to be the cause of coagulation disorders considering long-term antibiotic therapy, especially cephalosporins, inadequate diet and abnormal liver function. After supplementation with 20 mg of vitamin K, coagulation dysfunction was rescued the next day and serious consequences were effectively prevented.", + "summary_subclaims": [ + "The patient was a 71-year-old male.", + "The patient had pulmonary infection.", + "The patient had a severe coagulation disorder.", + "The patient had no bleeding symptoms.", + "The patient had a history of Parkinson's disease.", + "The patient had a history of Alzheimer's disease.", + "The patient had cardiac insufficiency.", + "Coagulation tests were normal at the time of admission.", + "Prothrombin time (PT) at admission was 13.9 seconds.", + "The normal range for PT is 9.5-13.1 seconds.", + "Activated partial thromboplastin time (APTT) at admission was 30.2 seconds.", + "The normal range for APTT is 25.1-36.5 seconds.", + "Coagulation tests turned severely abnormal after 20 days.", + "Prothrombin time after 20 days was 136.1 seconds.", + "Activated partial thromboplastin time after 20 days was 54.8 seconds.", + "No anticoagulants such as warfarin were used.", + "No bleeding symptoms were observed.", + "Mixing studies with normal plasma showed a decrease in prothrombin times.", + "Vitamin K deficiency was thought to be the cause of coagulation disorders.", + "Long-term antibiotic therapy was considered as a factor.", + "Cephalosporins were specifically mentioned.", + "Inadequate diet was considered as a factor.", + "Abnormal liver function was considered as a factor.", + "The patient received 20 mg of vitamin K.", + "Coagulation dysfunction was rescued the next day.", + "Serious consequences were effectively prevented." + ] + }, + { + "id": "multiclinsum_test_2671_en.txt", + "fulltext": "A previously healthy 15-year-old boy presented with acute-onset left testicular pain for 12 h. He was afebrile, denied having any dysuria or hematuria, and denied any history of previous trauma. Physical examination showed a left testicle that was diffusely enlarged without any discrete masses, On palpation, the left testis was tender and swollen. The right testis was normal. Ultrasonography shows heterogeneous enlargement of the left testis with areas of decreased echogenicity. No associated masses are identified. Testicular doppler ultrasonography shows absent blood flow. Surgical exploration was decided urgently to save the testicles.\nUpon surgical exploration, the whole testis and epididymis were diffusely enlarged and dusty dark , consequently, unilateral left orchiectomy was performed. The Microscopic sections show diffuse interstitial hemorrhage with intact seminiferous tubules and full spermatogenesis . There was no sign of thrombosis, vasculitis, tumors, tumor necrosis, or any other pathologies that could be concurrently present or lead to testicular bleeding.", + "fulltext_subclaims": [ + "The patient is a 15-year-old boy.", + "He had acute-onset left testicular pain for 12 h.", + "He was afebrile.", + "He denied having any dysuria.", + "He denied having any hematuria.", + "He denied any history of previous trauma.", + "Physical examination showed a left testicle that was diffusely enlarged without any discrete masses.", + "On palpation, the left testis was tender and swollen.", + "The right testis was normal.", + "Ultrasonography showed heterogeneous enlargement of the left testis with areas of decreased echogenicity.", + "No associated masses are identified.", + "Testicular doppler ultrasonography showed absent blood flow.", + "Surgical exploration was decided urgently to save the testicles.", + "Upon surgical exploration, the whole testis and epididymis were diffusely enlarged and dusty dark.", + "Unilateral left orchiectomy was performed.", + "Microscopic sections showed diffuse interstitial hemorrhage with intact seminiferous tubules and full spermatogenesis.", + "There was no sign of thrombosis.", + "There was no sign of vasculitis.", + "There was no sign of tumors.", + "There was no sign of tumor necrosis.", + "There was no sign of any other pathologies that could be concurrently present or lead to testicular bleeding." + ], + "summary": "We report a case of a 15-year-old boy who had been experiencing intense, left scrotal pain for the previous twelve hours. No previous history of trauma or bleeding disorders. The left testis was enlarged and tender. Left orchiectomy was performed. The entire testis was dusty and dark grossly. Microscopic sections show diffuse intratesticular bleeding with intact seminiferous tubules and spermatogenesis.", + "summary_subclaims": [ + "The patient is a 15-year-old boy.", + "He had been experiencing intense, left scrotal pain for the previous twelve hours.", + "There was no previous history of trauma.", + "There was no previous history of bleeding disorders.", + "The left testis was enlarged.", + "The left testis was tender.", + "Left orchiectomy was performed.", + "The entire testis was dusty and dark grossly.", + "Microscopic sections show diffuse intratesticular bleeding.", + "Microscopic sections show intact seminiferous tubules.", + "Microscopic sections show spermatogenesis." + ] + }, + { + "id": "multiclinsum_test_2555_en.txt", + "fulltext": "A 29-year-old lady was diagnosed with metastatic NPC with cervical nodal, lung and bone metastases in December 2014. Her disease progressed despite multiple lines of chemotherapy including gemcitabine and cisplatin (3 cycles from December 2014 to March 2015)cisplatin plus 5-fluorouracil (1 cycle in April 2015) which was changed to docetaxel plus cisplatin because of 5-fluorouracil allergy (3 cycles from April 2015 to June 2015), gemcitabine and carboplatin (6 cycles from November 2015 to March 2016) capecitabine (6 cycles from April 2016 to August 2016), and metronomic cyclophosphamide (from August 2016 to September 2016). Radical chemoradiation with cisplatin was given to her progressive neck nodes in July 2015. Her lung metastases later further progressed resulting in mild dyspnea and her plasma Epstein-Barr virus (EBV) deoxyribonucleic acid (DNA) rose from 4919 to 119,125 copies/ml . Pembrolizumab, an anti-PD-1 inhibitor was considered owing to very limited further treatment options. Her archived neck lymph node specimens sent for PD-L1 expression with immunohistochemical staining revealed that the tumor proportion score was 100 and the combined positive score was 101, indicating that a promising response to ICI was expected. She denied any past medical history of tuberculosis. She then received pembrolizumab at 2 mg/kg every three weeks since September 2016. Her dyspnea and lung metastases improved and reduced in number dramatically after only two cycles of pembrolizumab, accompanied by a slump of EBV DNA to 83 copies/ml . She experienced mild irAEs with hypocortisolism and hypothyroidism which were effectively managed with hormone replacement therapy. In May 2018, she presented with a sudden onset of severe, colicky and localized right lower abdominal pain, projectile vomiting and bloody diarrhea with mucus, and persistent fever (temperature > 38.6 degrees Celsius). Initially immune-related enteritis/colitis was suspected and pembrolizumab was suspended. Positron emission tomography with integrated computed tomography (PET-CT) of the abdomen showed terminal ileitis with multiple enlarged mesenteric lymph nodes Colonoscopy was performed and the inflamed terminal ileum was biopsied, which exhibited multiple caseating granulomas with Langerhan cells, compatible with tuberculous ileitis (microscopic images captured by Nikon model DS-FI3 attached to Nikon Eclipse Ni microscope viewed by Application DS-L4 Viewer Software Ver1.2.0) . Otherwise, the pathology did not show any features of inflammatory bowel disease or immune-related enteritis. Though Ziehl–Neelsen stain did not identify any acid-fast bacilli, polymerase chain reaction test for TB of the ileal biopsy and interferon gamma release assay (IGRA) with QuantiFERON TB Gold Plus were both strongly positive. She immediately received anti-TB medication including rifampicin, ethambutol, pyrazinamide and isoniazid for 1 year following our microbiologist’s suggestion. Her terminal ileitis and the enlarged mesenteric lymphadenitis resolved in the follow-up PET-CT scan 9 months later. Colonoscopy performed 15 months after the last one confirmed complete resolution of her ileitis .\nHowever, her lung metastases worsened again 7 months after anti-TB treatment , concurrent with an elevated plasma EBV DNA of 2826 copies/ml following pembrolizumab interruption. In light of her current progressive metastases and the prior extraordinary response to pembrolizumab, she was re-challenged with pembrolizumab in December 2018 together with her anti-TB treatment. PET-CT scan 5 months later showed promising tumour shrinkage . She is still receiving pembrolizumab with no evidence of TB relapse or other irAE.", + "fulltext_subclaims": [ + "The patient was diagnosed with metastatic NPC with cervical nodal, lung and bone metastases in December 2014.", + "Her disease progressed despite multiple lines of chemotherapy.", + "She received gemcitabine and cisplatin from December 2014 to March 2015.", + "She received cisplatin plus 5-fluorouracil in April 2015.", + "She was changed to docetaxel plus cisplatin because of 5-fluorouracil allergy from April 2015 to June 2015.", + "She received gemcitabine and carboplatin from November 2015 to March 2016.", + "She received capecitabine from April 2016 to August 2016.", + "She received metronomic cyclophosphamide from August 2016 to September 2016.", + "Radical chemoradiation with cisplatin was given to her progressive neck nodes in July 2015.", + "Her lung metastases later further progressed.", + "Her plasma EBV DNA rose from 4919 to 119,125 copies/ml.", + "Pembrolizumab was considered owing to very limited further treatment options.", + "Her archived neck lymph node specimens showed a tumor proportion score of 100.", + "Her archived neck lymph node specimens showed a combined positive score of 101.", + "She received pembrolizumab at 2 mg/kg every three weeks since September 2016.", + "Her dyspnea and lung metastases improved after two cycles of pembrolizumab.", + "Her EBV DNA slumped to 83 copies/ml after two cycles of pembrolizumab.", + "She experienced mild irAEs with hypocortisolism and hypothyroidism.", + "She denied any past medical history of tuberculosis.", + "In May 2018, she presented with a sudden onset of severe, colicky and localized right lower abdominal pain.", + "She had projectile vomiting and bloody diarrhea with mucus.", + "She had a persistent fever with temperature > 38.6 degrees Celsius.", + "PET-CT of the abdomen showed terminal ileitis with multiple enlarged mesenteric lymph nodes.", + "Colonoscopy was performed and the inflamed terminal ileum was biopsied.", + "The biopsy showed multiple caseating granulomas with Langerhan cells, compatible with tuberculous ileitis.", + "The pathology did not show any features of inflammatory bowel disease.", + "The pathology did not show any features of immune-related enteritis.", + "Ziehl–Neelsen stain did not identify any acid-fast bacilli.", + "Polymerase chain reaction test for TB of the ileal biopsy was strongly positive.", + "IGRA with QuantiFERON TB Gold Plus was strongly positive.", + "She received anti-TB medication including rifampicin, ethambutol, pyrazinamide and isoniazid for 1 year.", + "Her terminal ileitis and enlarged mesenteric lymphadenitis resolved in the follow-up PET-CT scan 9 months later.", + "Colonoscopy performed 15 months after the last one confirmed complete resolution of her ileitis.", + "Her lung metastases worsened again 7 months after anti-TB treatment.", + "Her plasma EBV DNA was 2826 copies/ml following pembrolizumab interruption.", + "She was re-challenged with pembrolizumab in December 2018.", + "PET-CT scan 5 months later showed promising tumour shrinkage.", + "She is still receiving pembrolizumab with no evidence of TB relapse or other irAE." + ], + "summary": "A 29-year-old lady with metastatic NPC involving the cervical nodes, lungs and bones started pembrolizumab after failure to multiple lines of chemotherapy. She complained of sudden onset of abdominal pain, vomiting and bloody diarrhea with mucus 21 months after pembrolizumab. Colonoscopy revealed terminal ileitis with multiple caseating granulomas with Langerhan cells. Serum interferon gamma release assay was strongly positive. She was treated with anti-TB medication and was later rechallenged with pembrolizumab for her progressive lung metastases without further TB relapse while her lung metastases were brought under control again.", + "summary_subclaims": [ + "The patient is a 29-year-old lady.", + "She has metastatic NPC involving the cervical nodes, lungs and bones.", + "She started pembrolizumab after failure to multiple lines of chemotherapy.", + "She complained of sudden onset of abdominal pain, vomiting and bloody diarrhea with mucus 21 months after pembrolizumab.", + "Colonoscopy revealed terminal ileitis with multiple caseating granulomas with Langerhan cells.", + "Serum interferon gamma release assay was strongly positive.", + "She was treated with anti-TB medication.", + "She was later rechallenged with pembrolizumab for her progressive lung metastases.", + "There was no further TB relapse.", + "Her lung metastases were brought under control again." + ] + }, + { + "id": "multiclinsum_test_2905_en.txt", + "fulltext": "The patient provided informed consent for the procedure and the publication of anonymized case details presented in this report.\nA 52-year-old woman (height, 155 cm; weight, 64 kg) with HAE was scheduled for laparoscopic cholecystectomy. An immunology clinic confirmed the presence of HAE at the age of 39, and the patient was diagnosed with type-I HAE according to genetic testing. Tranexamic acid 1000 mg and danazol 100 mg had been administered daily for long-term symptom control. In addition, prednisolone 4 mg was orally administered due suspected systemic lupus erythematosus. Preoperative blood tests revealed mild liver dysfunction (total bilirubin, 1.9 mg/dL; aspartate aminotransferase, 41 IU/L; alanine aminotransferase, 75 IU/L). Chest X-ray imaging, electrocardiography, and respiratory function tests were normal.\nPreviously, the patient had repeatedly developed signs of angioedema at a frequency of once every 2–3 months. Nasal obstruction, edema around the cervical region, or a feeling of discomfort in the throat due to angioedema were reported, necessitating emergency infusion with C1-esterase inhibitor concentrate (Berinert® P, CSL Behring, Germany) to relieve the symptoms.\nDuring preoperative planning of anesthesia for the current surgery, avoiding tracheal intubation to reduce the risk for tracheal angioedema was considered. Wall-lifting laparoscopic surgery was scheduled so that surgical stress could be managed using combined spinal-epidural anesthesia.\nDanazol, tranexamic acid, and prednisolone were administered orally on the morning of the day of surgery; in addition, 1500 U of C1-esterase inhibitor was administered intravenously 2 h before the surgery.\nAn epidural catheter was inserted through the intervertebral space at T9/10, and spinal anesthesia was instilled using 0.5% hyperbaric bupivacaine 3 mL and fentanyl 15 μg via the L3/4 intervertebral space. In addition, 5 mL of 0.375% levobupivacaine solution and 3 mg of morphine were administered via the epidural catheter. Anesthesia was achieved below the T4 cutaneous level. In accordance with the patient’s request, she was sedated by intermittent administration of midazolam (7 mg total) and continuous infusion of propofol (0.8–1.6 mg/kg/h). Oxygen was administered at 4 l/min via a face mask, and peripheral oxygen saturation was maintained at 100% through the operation. Blood pressure was maintained by intermittent administration of phenylephrine. A single-hole, Nishii-type lifting laparoscopic surgery, without pneumoperitoneum (i.e., gasless) was completed uneventfully. The operation duration was 2 h and 45 min, and anesthesia duration was 3 h and 20 min. After confirming the absence of complications in respiratory status, she was returned to the ward and discharged uneventfully on postoperative day 3.", + "fulltext_subclaims": [ + "The patient provided informed consent for the procedure and the publication of anonymized case details presented in this report.", + "The patient was a 52-year-old woman with a height of 155 cm and weight of 64 kg.", + "The patient had a diagnosis of HAE.", + "An immunology clinic confirmed the presence of HAE at the age of 39.", + "The patient was diagnosed with type-I HAE according to genetic testing.", + "Tranexamic acid 1000 mg and danazol 100 mg had been administered daily for long-term symptom control.", + "Prednisolone 4 mg was orally administered due to suspected systemic lupus erythematosus.", + "Preoperative blood tests revealed mild liver dysfunction.", + "Chest X-ray imaging, electrocardiography, and respiratory function tests were normal.", + "The patient had repeatedly developed signs of angioedema at a frequency of once every 2–3 months.", + "Nasal obstruction, edema around the cervical region, or a feeling of discomfort in the throat due to angioedema were reported.", + "Emergency infusion with C1-esterase inhibitor concentrate (Berinert® P, CSL Behring, Germany) was necessary to relieve symptoms.", + "During preoperative planning of anesthesia, avoiding tracheal intubation to reduce the risk for tracheal angioedema was considered.", + "Wall-lifting laparoscopic surgery was scheduled.", + "Danazol, tranexamic acid, and prednisolone were administered orally on the morning of the day of surgery.", + "1500 U of C1-esterase inhibitor was administered intravenously 2 h before the surgery.", + "An epidural catheter was inserted through the intervertebral space at T9/10.", + "Spinal anesthesia was instilled using 0.5% hyperbaric bupivacaine 3 mL and fentanyl 15 μg via the L3/4 intervertebral space.", + "5 mL of 0.375% levobupivacaine solution and 3 mg of morphine were administered via the epidural catheter.", + "Anesthesia was achieved below the T4 cutaneous level.", + "Midazolam was intermittently administered for sedation.", + "Propofol was continuously infused for sedation.", + "Oxygen was administered at 4 l/min via a face mask.", + "Peripheral oxygen saturation was maintained at 100% through the operation.", + "Blood pressure was maintained by intermittent administration of phenylephrine.", + "A single-hole, Nishii-type lifting laparoscopic surgery, without pneumoperitoneum, was completed uneventfully.", + "The operation duration was 2 h and 45 min.", + "The anesthesia duration was 3 h and 20 min.", + "The patient was returned to the ward after confirming the absence of complications in respiratory status.", + "The patient was discharged uneventfully on postoperative day 3." + ], + "summary": "A 52-year-old female with hereditary angioedema was scheduled for laparoscopic cholecystectomy. C1-esterase inhibitor, Danazol, tranexamic acid, and prednisolone were administered on the day of surgery. An epidural catheter was inserted through the intervertebral space at T9/10, and spinal anesthesia was instilled via the L3/4 intervertebral space. A single-hole, Nishii-type lifting laparoscopic surgery, without pneumoperitoneum (i.e., gasless) was completed uneventfully.", + "summary_subclaims": [ + "The patient is a 52-year-old female.", + "The patient has hereditary angioedema.", + "The patient was scheduled for laparoscopic cholecystectomy.", + "C1-esterase inhibitor was administered on the day of surgery.", + "Danazol was administered on the day of surgery.", + "Tranexamic acid was administered on the day of surgery.", + "Prednisolone was administered on the day of surgery.", + "An epidural catheter was inserted through the intervertebral space at T9/10.", + "Spinal anesthesia was instilled via the L3/4 intervertebral space.", + "A single-hole, Nishii-type lifting laparoscopic surgery was performed.", + "The surgery was performed without pneumoperitoneum.", + "The surgery was completed uneventfully." + ] + }, + { + "id": "multiclinsum_test_1217_en.txt", + "fulltext": "A 38-year-old male patient presented to our hospital with right side motor weakness that had started 8 months earlier. He had visited another hospital when the symptoms had started and had been diagnosed with advanced gastric adenocarcinoma with a single metastatic lesion in the left thalamus . He had undergone gamma knife radiosurgery (GKRS) at the other hospital. However, due to brain edema and deterioration of his overall condition, systemic chemotherapy had not been performed.\nA physical examination revealed grade 4 motor weakness in the upper and lower right limbs. Laboratory findings revealed mild hypochromic microcytic anemia but were otherwise non-specific. Follow-up abdominal computed tomography (CT) showed aggravation of an advanced gastric malignancy with multiple metastatic regional lymph nodes, and new hepatic, left adrenal, and peritoneal metastases were also observed . Follow-up brain magnetic resonance imaging (MRI) showed a mild increase in the size of the metastasis in the left thalamus . He was only given palliative treatment and discharged.\nFive months later the patient was admitted to our neurosurgery department with a severe headache. A brain MRI showed a slight increase in the previous mass and several newly developed metastases with surrounding edema . Repeated GKRS was performed for both recurrent and new lesions. However, his symptoms persisted and his general condition worsened. A pathological examination of the endoscopically biopsied tissue revealed moderately differentiated adenocarcinoma with glandular fusion in a cribriform pattern . By immunohistochemistry, the tumor cells were completely negative for PD1, but showed weak to moderate cytoplasmic positivity for PDL1 . We gave the patient an injection of pembrolizumab (Keytruda) 200 mg.\nTwo weeks after the injection of pembrolizumab, he returned to our hospital, reporting that his neurological symptoms had dramatically improved and that his headaches no longer occurred. He insisted that the treatment be continued, and after three doses of pembrolizumab, the patient underwent an abdominal CT and brain MRI. The abdominal CT revealed a partial response of the gastric cancer, liver, lymph node, and brain metastases, and the brain MRI showed that the thalamic metastasis had achieved a stable state and that there had been a dramatic reduction of the newly developed brain metastases .\nThe neurological symptoms were markedly improved after 3 doses of pembrolizumab. A follow-up physical examination after treatment revealed grade 3 motor weakness in his right lower limb and grade 4 motor weakness in his upper limb. Although a new brain lesion developed after 7 months of pembrolizumab treatment, his neurological symptoms and signs were not aggravated and he is being treated with systemic chemotherapy and pembrolizumab. The patient is currently still alive and in fair general condition 26 months after the initial diagnosis.", + "fulltext_subclaims": [ + "The patient is a 38-year-old male.", + "He presented with right side motor weakness that had started 8 months earlier.", + "He had been diagnosed with advanced gastric adenocarcinoma with a single metastatic lesion in the left thalamus.", + "He had undergone gamma knife radiosurgery at the other hospital.", + "Systemic chemotherapy had not been performed due to brain edema and deterioration of his overall condition.", + "A physical examination revealed grade 4 motor weakness in the upper and lower right limbs.", + "Follow-up abdominal CT showed aggravation of an advanced gastric malignancy with multiple metastatic regional lymph nodes.", + "New hepatic, left adrenal, and peritoneal metastases were observed.", + "Follow-up brain MRI showed a mild increase in the size of the metastasis in the left thalamus.", + "He was only given palliative treatment and discharged.", + "Five months later the patient was admitted with a severe headache.", + "A brain MRI showed a slight increase in the previous mass and several newly developed metastases with surrounding edema.", + "Repeated GKRS was performed for both recurrent and new lesions.", + "A pathological examination of the endoscopically biopsied tissue revealed moderately differentiated adenocarcinoma with glandular fusion in a cribriform pattern.", + "The tumor cells were completely negative for PD1.", + "The tumor cells showed weak to moderate cytoplasmic positivity for PDL1.", + "The patient was given an injection of pembrolizumab 200 mg.", + "Two weeks after the injection, the patient reported that his neurological symptoms had dramatically improved.", + "The patient insisted that the treatment be continued.", + "After three doses of pembrolizumab, the patient underwent an abdominal CT and brain MRI.", + "The abdominal CT revealed a partial response of the gastric cancer, liver, lymph node, and brain metastases.", + "The brain MRI showed that the thalamic metastasis had achieved a stable state.", + "The brain MRI showed a dramatic reduction of the newly developed brain metastases.", + "The neurological symptoms were markedly improved after 3 doses of pembrolizumab.", + "A follow-up physical examination after treatment revealed grade 3 motor weakness in his right lower limb.", + "A follow-up physical examination after treatment revealed grade 4 motor weakness in his upper limb.", + "A new brain lesion developed after 7 months of pembrolizumab treatment.", + "His neurological symptoms and signs were not aggravated.", + "He is being treated with systemic chemotherapy and pembrolizumab.", + "The patient is currently still alive 26 months after the initial diagnosis." + ], + "summary": "We herein discuss a case of a 38-year-old man initially diagnosed with a gastric cancer brain metastasis. At first, only stereotactic radiosurgery (SRS) was performed, but it was not effective. After the brain and systemic metastases progressed, SRS and anti-PD-1 therapy were administered in combination, and the brain and intra-abdominal metastatic lesions responded satisfactorily.", + "summary_subclaims": [ + "The patient was a 38-year-old man.", + "The patient was initially diagnosed with a gastric cancer brain metastasis.", + "At first, only stereotactic radiosurgery (SRS) was performed.", + "Stereotactic radiosurgery was not effective.", + "The brain and systemic metastases progressed.", + "SRS and anti-PD-1 therapy were administered in combination.", + "The brain and intra-abdominal metastatic lesions responded satisfactorily." + ] + }, + { + "id": "multiclinsum_test_3268_en.txt", + "fulltext": "We present the case of a 10-year-old girl whose left arm was injured by a fall from a height of approximately 1.5 m. The patient was transported to a nearby hospital on the same day and referred for treatment on the second day after the injury. X-rays revealed a modified Gartland type 2B supracondylar humerus fracture, a Bado type I Monteggia fracture–dislocation, and a Salter–Harris type II distal radius physeal fracture with volar displacement in the ipsilateral upper extremity. No neurovascular symptoms or open wounds were noted. Surgical treatment was performed on the third day after the injury. Surgery was performed with the patient in the supine position. Reduction and fixation of the distal radius physeal fracture were performed to restore radial length prior to reduction of the humeroradial joint. The distal radius physeal fracture was reduced and fixed using steel wire-connected pins (JuNction, Arata, Japan) through closed reduction and percutaneous pinning. Next, manual reduction of the humeroradial joint was performed; however, it was difficult to achieve the reduction position. It was considered that the inability to achieve reduction was the interposition of soft tissue within the humeroradial joint. The supracondylar humerus fracture showed no progression of dislocation during the reduction maneuver; therefore, open reduction of the humeroradial joint was performed. The tourniquet was inflated to 200 mmHg and used for 60 min. An open reduction of the radial head was performed through a posterior approach. With the posterior approach, triceps splitting is performed proximal to the olecranon, and as per the Boyd approach, the humeroradial joint was exposed by detaching the anconeus muscle from the radial side of the ulna distal to the olecranon. The annular ligament was incarcerated within the humeroradial joint, preventing reduction. A partial longitudinal incision was made through the annular ligament, allowing for easy reduction of the radial head. The absence of instability in the forearm during pronation and supination was confirmed following the reduction of the humeroradial joint. Reduction of the humeroradial joint resulted in an appropriate reduction position for the ulnar diaphyseal fracture. The ulnar diaphysis fracture was fixed with a titanium elastic nail (TEN) to prevent displacement. Steel wire-connected pins were used to fix a supracondylar humerus fracture. The postoperative X-rays showed a good reduction position. Postoperatively, a long arm splint was applied to the forearm in a supinated position, and no postoperative drainage was performed. At 5 weeks postoperatively, as callus formation was favorable, the steel wire-connected pins for the supracondylar humerus and distal radius physeal fractures, along with the splint fixation, was removed, and range of motion training for the elbow and wrist joints was initiated. At approximately 3 months postoperatively, bone union was confirmed on X-rays. Approximately 6 months postoperatively, the ulnar TEN was removed. Intraoperatively, Fluoroscopic imaging under general anesthesia was used to evaluate the instability of the humeroradial joint. No instability was noted in the humeroradial joint during forearm pronation.\n\nApproximately 1 year after surgery, the elbow joint range of motion was 10° extension, 150° flexion, 90° pronation, and 90° supination, with no range of motion limitation. X-rays showed that bone union had been achieved at each fracture site with good alignment. The patient was unaware of any symptoms in her daily life, and her Mayo Elbow Performance score was 100.\n\n", + "fulltext_subclaims": [ + "The patient was a 10-year-old girl.", + "The injury occurred due to a fall from a height of approximately 1.5 m.", + "The patient was transported to a nearby hospital on the same day.", + "X-rays revealed a modified Gartland type 2B supracondylar humerus fracture.", + "X-rays revealed a Bado type I Monteggia fracture–dislocation.", + "X-rays revealed a Salter–Harris type II distal radius physeal fracture with volar displacement.", + "No neurovascular symptoms were noted.", + "Surgical treatment was performed on the third day after the injury.", + "The distal radius physeal fracture was reduced and fixed using steel wire-connected pins.", + "Manual reduction of the humeroradial joint was performed.", + "It was difficult to achieve the reduction position.", + "The inability to achieve reduction was considered to be due to the interposition of soft tissue within the humeroradial joint.", + "The tourniquet was inflated to 200 mmHg.", + "The tourniquet was used for 60 min.", + "An open reduction of the radial head was performed through a posterior approach.", + "A posterior approach involved triceps splitting proximal to the olecranon.", + "The annular ligament was incarcerated within the humeroradial joint.", + "A partial longitudinal incision was made through the annular ligament.", + "The absence of instability in the forearm during pronation and supination was confirmed.", + "The ulnar diaphysis fracture was fixed with a titanium elastic nail.", + "Steel wire-connected pins were used to fix the supracondylar humerus fracture.", + "Postoperative X-rays showed a good reduction position.", + "A long arm splint was applied to the forearm in a supinated position.", + "At 5 weeks postoperatively, callus formation was favorable.", + "Steel wire-connected pins for the supracondylar humerus and distal radius physeal fractures were removed.", + "The splint fixation was removed at 5 weeks postoperatively.", + "Range of motion training for the elbow and wrist joints was initiated.", + "Bone union was confirmed on X-rays at approximately 3 months postoperatively.", + "The ulnar titanium elastic nail was removed approximately 6 months postoperatively.", + "Fluoroscopic imaging under general anesthesia was used to evaluate the instability of the humeroradial joint.", + "No instability was noted in the humeroradial joint during forearm pronation.", + "Approximately 1 year after surgery, the elbow joint range of motion was 10° extension.", + "Approximately 1 year after surgery, the elbow joint range of motion was 150° flexion.", + "Approximately 1 year after surgery, the elbow joint range of motion was 90° pronation.", + "Approximately 1 year after surgery, the elbow joint range of motion was 90° supination.", + "X-rays showed that bone union had been achieved at each fracture site.", + "The patient was unaware of any symptoms in her daily life.", + "The Mayo Elbow Performance score was 100." + ], + "summary": "We present the case of a 10-year-old girl with concurrent ipsilateral arm supracondylar humerus fracture with Monteggia fracture-dislocation and distal radius physeal fracture, which were treated with closed reduction and percutaneous pinning. The Monteggia fracture-dislocation was addressed with open reduction via a posterior approach and fixation using titanium elastic nails. The postoperative recovery was favorable. At 1-year postoperative follow-up, the Mayo Elbow Performance score was 100 points, and no limitations in joint range of motion were noted.", + "summary_subclaims": [ + "The patient is a 10-year-old girl.", + "The patient had a concurrent ipsilateral arm supracondylar humerus fracture.", + "The patient had a Monteggia fracture-dislocation.", + "The patient had a distal radius physeal fracture.", + "The fractures were treated with closed reduction and percutaneous pinning.", + "The Monteggia fracture-dislocation was addressed with open reduction via a posterior approach.", + "The Monteggia fracture-dislocation was fixed using titanium elastic nails.", + "The postoperative recovery was favorable.", + "At 1-year postoperative follow-up, the Mayo Elbow Performance score was 100 points.", + "No limitations in joint range of motion were noted at 1-year postoperative follow-up." + ] + }, + { + "id": "multiclinsum_test_1344_en.txt", + "fulltext": "A previously healthy 64-year-old male was admitted to the hospital with headache, fever and later imbalance, blurred vision and general slowness. Patient’s neurological examination revealed nuchal rigidity and general clumsiness. Blood tests showed leukocytosis (11.90 × 109/l) and an increased C-reactive protein (47 mg/l). A computer tomography (CT) scan of the brain showed normal results. The cerebrospinal fluid (CSF) was clear but yellowish and had a slightly elevated count of erythrocytes (10 × 106/l), high levels of leukocytes (940 × 106/l; 40% lymphocytes and 56% granulocytes), elevated protein levels (1,696 mg/l), and hypoglycorrhachia (0.9 mmol/l). Bacterial cultures and CSF staining remained negative.\nMeningitis was suspected, and the patient was treated with intravenous (IV) dexamethasone (10 mg four times a day), ceftriaxone (4 g daily), and acyclovir (750 mg three times a day). Four days after admission, when his C-reactive protein had decreased to 10 mg/l, viral meningitis was considered the most probable cause. As a result, the treatment with ceftriaxone and dexamethasone was discontinued, but the acyclovir treatment continued.\nNine days after admission, the patient’s general condition slowly deteriorated, and he became increasingly somnolent. The patient was restarted on IV ceftriaxone (2 g daily, which was increased to 4 g daily one day later), in combination with doxycycline (100 mg twice a day) due to the suspicion of borreliosis. On the following day, brain magnetic resonance imaging (MRI) was performed, and it revealed signs compatible with ventriculitis in the right lateral ventricle and the third ventricle .\nEleven days after admission, the patient’s consciousness rapidly declined. A new CT scan of the brain revealed hydrocephalus and a mild midline shift, attributed to the enlarged right lateral ventricle , so an emergency ventriculostomy was performed. Cerebrospinal fluid obtained during the operation appeared clear but yellowish, with later debris observed in the CSF collector bag. Doxycycline was discontinued. Due to the neurosurgeon’s suspicion of a poor clinical response to ceftriaxone, it was switched to IV cefotaxime (2 g three times a day), with the dosage increased to 2 g four times a day by an infection consultant two days later. No signs of renal dysfunction were detected, and serum creatinine levels remained within the normal range. The patient’s condition rapidly improved after the ventriculostomy and antibiotic treatment. On the 21st day after admission, the ventriculostomy was closed.\nIn the Gram staining of the CSF sample obtained from the ventriculostomy at the time of the operation, chains of gram-positive cocci were observed inside polymorphonuclear leukocytes. The bacteria’s morphology resembled that of streptococci. Bacterial cultures of both CSF and blood remained negative. The sample, which displayed bacteria in the Gram staining, and another CSF sample taken one day later, were analyzed using in-house bacterial 16s ribosomal RNA gene amplification by polymerase chain reaction (PCR) with high sensitivity for both aerobic and anaerobic bacteria, followed by sequencing. The analysis of both samples tested positive for S. intermedius.\nNo clinical signs of infective endocarditis were observed in further assessments, and echocardiography was not performed. The patient mentioned a history of chronic dental problems. An orthopantomography revealed advanced periodontal destruction in several teeth, and periapical abscesses were found in teeth 33 and 31 . Maxillary teeth 15 and 16 were urgently extracted, followed by the extraction of teeth 17, 23, 24, 31, 32, 33, and 43. During the latter operation, prophylactic metronidazole (500 mg three times a day) was initiated for three days. The patient continued to improve and was discharged in good condition one month after admission, with only slight left-sided hemiparesis. The clinical time course, and the most important examinations and interventions of the patient during hospitalisation are illustrated in Fig. .", + "fulltext_subclaims": [ + "A previously healthy 64-year-old male was admitted to the hospital with headache, fever and later imbalance, blurred vision and general slowness.", + "Patient’s neurological examination revealed nuchal rigidity and general clumsiness.", + "Blood tests showed leukocytosis (11.90 × 109/l) and an increased C-reactive protein (47 mg/l).", + "A computer tomography (CT) scan of the brain showed normal results.", + "The cerebrospinal fluid (CSF) was clear but yellowish.", + "The CSF had a slightly elevated count of erythrocytes (10 × 106/l).", + "The CSF had high levels of leukocytes (940 × 106/l; 40% lymphocytes and 56% granulocytes).", + "The CSF had elevated protein levels (1,696 mg/l).", + "The CSF had hypoglycorrhachia (0.9 mmol/l).", + "Bacterial cultures and CSF staining remained negative.", + "Meningitis was suspected.", + "The patient was treated with intravenous (IV) dexamethasone (10 mg four times a day).", + "The patient was treated with ceftriaxone (4 g daily).", + "The patient was treated with acyclovir (750 mg three times a day).", + "Four days after admission, when his C-reactive protein had decreased to 10 mg/l, viral meningitis was considered the most probable cause.", + "The treatment with ceftriaxone and dexamethasone was discontinued.", + "The acyclovir treatment continued.", + "Nine days after admission, the patient’s general condition slowly deteriorated.", + "The patient became increasingly somnolent.", + "The patient was restarted on IV ceftriaxone (2 g daily, which was increased to 4 g daily one day later).", + "The patient was treated with doxycycline (100 mg twice a day) due to the suspicion of borreliosis.", + "Brain magnetic resonance imaging (MRI) was performed.", + "The MRI revealed signs compatible with ventriculitis in the right lateral ventricle and the third ventricle.", + "Eleven days after admission, the patient’s consciousness rapidly declined.", + "A new CT scan of the brain revealed hydrocephalus and a mild midline shift, attributed to the enlarged right lateral ventricle.", + "An emergency ventriculostomy was performed.", + "Cerebrospinal fluid obtained during the operation appeared clear but yellowish.", + "Later debris was observed in the CSF collector bag.", + "Doxycycline was discontinued.", + "Due to the neurosurgeon’s suspicion of a poor clinical response to ceftriaxone, it was switched to IV cefotaxime (2 g three times a day).", + "The dosage of cefotaxime was increased to 2 g four times a day by an infection consultant two days later.", + "No signs of renal dysfunction were detected.", + "Serum creatinine levels remained within the normal range.", + "The patient’s condition rapidly improved after the ventriculostomy and antibiotic treatment.", + "On the 21st day after admission, the ventriculostomy was closed.", + "In the Gram staining of the CSF sample obtained from the ventriculostomy at the time of the operation, chains of gram-positive cocci were observed inside polymorphonuclear leukocytes.", + "The bacteria’s morphology resembled that of streptococci.", + "Bacterial cultures of both CSF and blood remained negative.", + "The sample, which displayed bacteria in the Gram staining, and another CSF sample taken one day later, were analyzed using in-house bacterial 16s ribosomal RNA gene amplification by polymerase chain reaction (PCR) with high sensitivity for both aerobic and anaerobic bacteria, followed by sequencing.", + "The analysis of both samples tested positive for S. intermedius.", + "No clinical signs of infective endocarditis were observed in further assessments.", + "Echocardiography was not performed.", + "The patient mentioned a history of chronic dental problems.", + "An orthopantomography revealed advanced periodontal destruction in several teeth.", + "Periapical abscesses were found in teeth 33 and 31.", + "Maxillary teeth 15 and 16 were urgently extracted.", + "Teeth 17, 23, 24, 31, 32, 33, and 43 were extracted.", + "During the latter operation, prophylactic metronidazole (500 mg three times a day) was initiated for three days.", + "The patient continued to improve and was discharged in good condition one month after admission, with only slight left-sided hemiparesis." + ], + "summary": "A 64-year-old male was admitted to the hospital with a headache, fever and later imbalance, blurred vision, and general slowness. Neurological examination revealed nuchal rigidity and general clumsiness. Meningitis was suspected, and the patient was treated with dexamethasone, ceftriaxone and acyclovir. A brain computer tomography (CT) scan was normal, and cerebrospinal fluid (CSF) Gram staining and bacterial cultures remained negative, so the antibacterial treatment was discontinued. Nine days after admission, the patient's condition deteriorated. The antibacterial treatment was restarted, and a brain magnetic resonance imaging revealed ventriculitis. A subsequent CT scan showed hydrocephalus, so a ventriculostomy was performed. In CSF Gram staining, chains of gram-positive cocci were observed. Bacterial cultures remained negative, but a bacterial PCR detected Streptococcus intermedius. An orthopantomography revealed advanced periodontal destruction in several teeth and periapical abscesses, which were subsequently operated on. The patient was discharged in good condition after one month.", + "summary_subclaims": [ + "The patient was a 64-year-old male.", + "The patient was admitted to the hospital with a headache.", + "The patient had fever.", + "The patient later had imbalance.", + "The patient had blurred vision.", + "The patient had general slowness.", + "Neurological examination revealed nuchal rigidity.", + "Neurological examination revealed general clumsiness.", + "Meningitis was suspected.", + "The patient was treated with dexamethasone.", + "The patient was treated with ceftriaxone.", + "The patient was treated with acyclovir.", + "A brain CT scan was normal.", + "CSF Gram staining remained negative.", + "Bacterial cultures remained negative.", + "The antibacterial treatment was discontinued.", + "Nine days after admission, the patient's condition deteriorated.", + "The antibacterial treatment was restarted.", + "A brain MRI revealed ventriculitis.", + "A CT scan showed hydrocephalus.", + "A ventriculostomy was performed.", + "In CSF Gram staining, chains of gram-positive cocci were observed.", + "Bacterial cultures remained negative.", + "A bacterial PCR detected Streptococcus intermedius.", + "An orthopantomography revealed advanced periodontal destruction in several teeth.", + "An orthopantomography revealed periapical abscesses.", + "The teeth with periapical abscesses were subsequently operated on.", + "The patient was discharged in good condition after one month." + ] + }, + { + "id": "multiclinsum_test_1701_en.txt", + "fulltext": "A 13-year-old male presented with complaints of painless swelling which was insidious in onset and gradually progressive over the right distal forearm for 3 years. He had multiple bony swelling all over the body which was asymptomatic.\nOn examination of the right wrist, there was an ulnar deviation of the wrist, which was passively correctable. The distal radioulnar joint (DRUJ) was unstable. There was a palpable, non-tender, osseous prominence in the distal aspect of the ulna . He had pain on the wrist range of motion and was unable to lift heavy objects. The skin over the affected site was normal with no distal neurovascular deficit. The examination of the ipsilateral elbow and other joints was normal.\nAnteroposterior and lateral radiographs of the right forearm show distal ulnar exostosis approximately 5*2 cm in size which was Type I according to Masada classification ( and ). At the wrist, a negative ulnar variance of 15 mm was observed. There was substantial radial bowing compared to the contralateral side and the length of the ulna was 3 cm shorter.\nThe patient was planned for excision of distal ulna osteochondroma through the Volar approach of the ulna . The osteotomy was done at proximal one-third of the ulna and was stabilized with LRS (two-pin above and two-pin below) and gradual ulnar lengthening was done . Deformity of the radius was not corrected as it will itself get remodeled with time ( and ). Postoperatively, the full range of motion of wrist and elbow is present . DRUJ is stable at subsequent follow-up, no additional procedure was done for DRUJ. We are still following up on the patient until skeletal maturity.", + "fulltext_subclaims": [ + "The patient is a 13-year-old male.", + "The patient had painless swelling in the right distal forearm.", + "The swelling was insidious in onset.", + "The swelling was gradually progressive over 3 years.", + "The patient had multiple bony swellings all over the body.", + "The bony swellings were asymptomatic.", + "On examination, there was ulnar deviation of the right wrist.", + "The ulnar deviation was passively correctable.", + "The distal radioulnar joint was unstable.", + "There was a palpable, non-tender, osseous prominence in the distal aspect of the ulna.", + "The patient had pain on wrist range of motion.", + "The patient was unable to lift heavy objects.", + "The skin over the affected site was normal.", + "There was no distal neurovascular deficit.", + "The ipsilateral elbow and other joints were normal.", + "Anteroposterior and lateral radiographs showed distal ulnar exostosis approximately 5*2 cm in size.", + "The distal ulnar exostosis was Type I according to Masada classification.", + "A negative ulnar variance of 15 mm was observed.", + "There was substantial radial bowing compared to the contralateral side.", + "The ulna was 3 cm shorter.", + "The patient was planned for excision of distal ulna osteochondroma through the Volar approach of the ulna.", + "The osteotomy was done at the proximal one-third of the ulna.", + "The osteotomy was stabilized with LRS (two-pin above and two-pin below).", + "Gradual ulnar lengthening was done.", + "Deformity of the radius was not corrected.", + "Deformity of the radius was not corrected as it will itself get remodeled with time.", + "Postoperatively, the full range of motion of wrist and elbow is present.", + "DRUJ is stable at subsequent follow-up.", + "No additional procedure was done for DRUJ.", + "The patient is still being followed up until skeletal maturity." + ], + "summary": "We report the case of multiple exostosis in a 13-year-old male with the right distal ulna osteochondroma with long-standing and progressive ulnar shortening and radial bowing treated with a limb reconstruction system. Our case is Type I Masada managed with excision of distal ulna osteochondroma and gradual ulnar lengthening without osteotomy of the radius.", + "summary_subclaims": [ + "The patient is a 13-year-old male.", + "The patient has multiple exostosis.", + "The patient has a right distal ulna osteochondroma.", + "The patient has long-standing and progressive ulnar shortening.", + "The patient has radial bowing.", + "The case is managed with excision of distal ulna osteochondroma.", + "The case is managed with gradual ulnar lengthening.", + "The case is managed without osteotomy of the radius." + ] + }, + { + "id": "multiclinsum_test_2153_en.txt", + "fulltext": "A 27-year-old man with recurrent fever, fatigue for more than 2 mo, and unconsciousness for 1 day was admitted to our emergency department.\nDuring the previous 2 mo, the patient had visited our outpatient department twice for fever and fatigue, his highest documented temperature having been 40.0°C. A chest computed tomography (CT) 6 wk prior to admission had shown bilateral lung infection . Routine blood testing revealed the following: White blood cell (WBC) count: 14.63 × 109/L, red blood cell (RBC) count: 3.35 × 1012/L, hemoglobin: 107.00 g/L, platelet count: 98 × 109/L, and C-reactive protein (CRP): 47.63 mg/L. Because the patient refused admission, the attending physician prescribed the antibiotic moxifloxacin (0.4 g daily) and asked him to attend the outpatient department for follow-up.\nThe patient had no notable history of past illness.\nThe patient had no notable personal or family history.\nThe patient’s temperature was 38.5°C, pulse rate 129 beats/min, respiratory rate 42 beats/min, transcutaneous saturation of oxygen 65%, and blood pressure 85/55 mmHg (11.33/7.33 kPa) on admission. His blood pressure increased to 113/78 mmHg (15.029/10.374 kPa) with infusion of 1 µg/kg/min norepinephrine. He was intubated and placed on mechanical ventilation in synchronous intermittent mandatory ventilation mode with the following settings: Fraction of inspired oxygen: 80%, positive end-expiratory pressure: 10 cm H2O, and pressure support: 15 cm H2O. His breathing was shallow with obvious moist crackles. No other abnormalities were detected on physical examination.\nRoutine blood testing 6 wk before admission revealed a high WBC count [14.63 × 109/L (normal range 3.5–9.5)], high CRP concentration [47.63 mg/L (< 8.0)], low RBC count [3.35 × 1012/L (4.30–5.80)], low hemoglobin [107.00 g/L (130–175)] and low platelet count [98 × 109/L (125–350)], indicating that he had inflammation and was anemic. Blood gas analysis on admission revealed anoxia and hyperventilation with a low partial pressures of oxygen [46.8 mmHg (80–100)] and carbon dioxide [24.3 mmHg (35–45)], pH: 7.516 (7.35–7.45), and transcutaneous oxygen saturation 75%. Routine blood testing on admission revealed a higher WBC count (34.45 × 109/L) and CRP concentration (80.78 mg/L) than 6 wk previously, together with a lower hemoglobin (90.00 g/L) and platelet count (80.78 mg/L) than previously, indicating that his inflammation and anemia had progressed. Additionally, his RBC count was 3.36 × 1012/L, mean corpuscular volume 120.1 fL (82.0–100.0), and mean corpuscular hemoglobin 40.8 pg (27.0–34.0). His erythrocyte sedimentation rate [106 mm/h (0–15)] and ferritin [> 1500.00 ng/mL (15–200)] provided further evidence of inflammation.\nChest CT 6 wk before admission had shown multiple patchy shadows with ill-defined boundaries and local consolidation in both lungs, indicating that he had bilateral pneumonia . On admission, CT showed more severe multiple patchy shadows in both lungs and consolidation, indicating that his pneumonia had worsened . B-mode ultrasonography of the liver and spleen on admission showed no obvious abnormalities.", + "fulltext_subclaims": [ + "A 27-year-old man with recurrent fever, fatigue for more than 2 mo, and unconsciousness for 1 day was admitted to our emergency department.", + "During the previous 2 mo, the patient had visited our outpatient department twice for fever and fatigue.", + "A chest computed tomography (CT) 6 wk prior to admission had shown bilateral lung infection.", + "Routine blood testing revealed the following: White blood cell (WBC) count: 14.63 × 109/L, red blood cell (RBC) count: 3.35 × 1012/L, hemoglobin: 107.00 g/L, platelet count: 98 × 109/L, and C-reactive protein (CRP): 47.63 mg/L.", + "The patient refused admission.", + "The attending physician prescribed the antibiotic moxifloxacin (0.4 g daily).", + "The patient had no notable history of past illness.", + "The patient had no notable personal or family history.", + "On admission, the patient’s temperature was 38.5°C, pulse rate 129 beats/min, respiratory rate 42 beats/min, transcutaneous saturation of oxygen 65%, and blood pressure 85/55 mmHg.", + "His blood pressure increased to 113/78 mmHg with infusion of 1 µg/kg/min norepinephrine.", + "He was intubated and placed on mechanical ventilation in synchronous intermittent mandatory ventilation mode.", + "The mechanical ventilation settings were: Fraction of inspired oxygen: 80%, positive end-expiratory pressure: 10 cm H2O, and pressure support: 15 cm H2O.", + "Routine blood testing 6 wk before admission revealed a high WBC count [14.63 × 109/L (normal range 3.5–9.5)], high CRP concentration [47.63 mg/L (< 8.0)], low RBC count [3.35 × 1012/L (4.30–5.80)], low hemoglobin [107.00 g/L (130–175)], and low platelet count [98 × 109/L (125–350)].", + "Blood gas analysis on admission revealed anoxia and hyperventilation with a low partial pressure of oxygen [46.8 mmHg (80–100)] and carbon dioxide [24.3 mmHg (35–45)], pH: 7.516 (7.35–7.45), and transcutaneous oxygen saturation 75%.", + "Routine blood testing on admission revealed a higher WBC count (34.45 × 109/L) and CRP concentration (80.78 mg/L) than 6 wk previously.", + "Chest CT 6 wk before admission had shown multiple patchy shadows with ill-defined boundaries and local consolidation in both lungs.", + "On admission, CT showed more severe multiple patchy shadows in both lungs and consolidation.", + "B-mode ultrasonography of the liver and spleen on admission showed no obvious abnormalities." + ], + "summary": "A 27-year-old man with recurrent fever, fatigue for > 2 mo, and unconsciousness for 1 day was admitted to our emergency department with a provisional diagnosis of severe pneumonia. Vancomycin and imipenem were administered and sputum collected for metagenomic next-generation sequencing. Epstein-Barr virus and Mycobacterium kansasii were detected. Additionally, chromosomal analysis showed duplications on chromosome 8. Two days later, repeat metagenomic next-generation sequencing was performed with blood culture. Cordyceps portugal, M. kansasii, and Candida portugal were detected, and duplications on chromosome 8 confirmed. Suspecting hematological disease, we aspirated a bone marrow sample from the iliac spine, examination of which showed evidence of infection. We added fluconazole as further antibiotic therapy. Seven days later, the patient's condition had not improved, prompting addition of methylprednisolone as an anti-inflammatory agent. Fortunately, this treatment was effective and the patient eventually recovered.", + "summary_subclaims": [ + "A 27-year-old man with recurrent fever, fatigue for > 2 mo, and unconsciousness for 1 day was admitted to our emergency department.", + "The provisional diagnosis was severe pneumonia.", + "Vancomycin and imipenem were administered.", + "Sputum was collected for metagenomic next-generation sequencing.", + "Epstein-Barr virus was detected.", + "Mycobacterium kansasii was detected.", + "Chromosomal analysis showed duplications on chromosome 8.", + "Repeat metagenomic next-generation sequencing was performed with blood culture.", + "Cordyceps portugal was detected.", + "M. kansasii was detected.", + "Candida portugal was detected.", + "Duplications on chromosome 8 were confirmed.", + "A bone marrow sample was aspirated from the iliac spine.", + "Examination of the bone marrow sample showed evidence of infection.", + "Fluconazole was added as further antibiotic therapy.", + "Seven days later, the patient's condition had not improved.", + "Methylprednisolone was added as an anti-inflammatory agent.", + "This treatment was effective.", + "The patient eventually recovered." + ] + }, + { + "id": "multiclinsum_test_3118_en.txt", + "fulltext": "Case history\nThe patient was a 67-year-old male patient. His chief complaint was that six hours before arriving at the hospital, he suffered a car accident which caused his persistent neck pain with no effective measures of pain relief and his neck could not move. There were no such accompanying symptoms as nausea, vomiting, dizziness, and headache.\n\nPhysical examination\nPhysical examination showed that the patient's limbs had no obvious limitation of movement and no symptoms of nervous injury. However, the right side of the patient's neck was significantly swollen, and the trachea was shifted to the left, The patient had no history of chronic diseases such as hypertension, diabetes, and coronary heart disease.\n\nImage analysis\nThe Neck Disability Index (NDI), JOA score, operation time, intraoperative blood loss, and perioperative complications were recorded before and after the operation. The improvement of the height of the injured intervertebral space, the situation of the reattachment of the facet joint, and the improvement of the Cobb angle of the C2–7 cervical lordosis (the acute angle formed by the vertical line of the lower edge of the C2 vertebral body and the vertical line of the lower edge of the C7 vertebral body, see 1b) before and after surgery was compared by imaging. The situation of interbody fusion was evaluated by imaging according to the modified Brantigan criteria.\n\nOperation\nSkull traction was performed immediately after admission. The traction weight of the patient was 4–10 Kg, and the average traction weight was (6.0 ± 2.0) Kg. At the same time, the patient's neck arterial-venous CTA examination was immediately performed, the result showed that did not find obvious contrast agent leakage. Subsequently, we closely observed the patient's condition and gave the patient symptomatic treatment. After continuous skull traction, we reexamination the patient's neck CT again, it was confirmed that the locked facet joints of the patient had been reattached. With the patient's condition tended to be stable, an elective operation of ACDF was performed on the injured segment of the cervical spine, and intravenous inhalation combined with anesthesia was used during the operation. The patient was placed in a supine position, and a right anterior cervical transverse incision was made about 5 cm in length. The skin, subcutaneous tissue, and platysma were cut. The gap between the cervical vascular sheath and the visceral sheath was isolated, and the trachea esophagus and esophagus were pulled to expose the anterior fascia of the vertebra. The C-arm X-ray fluoroscopy was used to determine the intervertebral disc of the injured segment, and the target intervertebral disc was confirmed under direct vision. The outer annulus fibrosus was incised with a sharp knife to observe the deep intervertebral disc injury. A spatula and nucleus pulposus forceps were used to completely remove the injured intervertebral disc from the endplate. The bilateral uncinate joints were examined and bitten with a thin-mouth plier. Under the microscope, we carefully handled the posterior edge of the vertebral body to fully expose the posterior longitudinal ligament, then picked up the posterior longitudinal ligament with a thin hook and cut it with scissors to expose the cerebral dura mater, and fully decompress the head and tail. The cerebral dura mater and the nerve roots on both sides were explored and confirmed again without compression. The bone graft beds on both sides of the endplate were repaired and rinsed with normal saline, and the gelatin sponge was used to stop bleeding. The size of the intervertebral fusion cage was determined, and the Cage loaded with autologous bone particles was inserted into the intervertebral space. Through C-arm fluoroscopy, the Cage position was good. The appropriate length of the anterior cervical titanium plate was selected, and the titanium plate was locked by locking screws. The internal fixation position was determined to be satisfactory by fluoroscopy again. Finally, the incision was washed with physiological saline, and we put a drainage tube in the incision before closing the incision.\n\nPostoperative management\nAfter the operation, antibiotics, hormones, and dehydration drugs were routinely used for 4–5 days, and atomization inhalation was performed for 3 days. The drainage tube was removed 48–72 h after operation. X-ray and CT were reexamined after the operation to understand the reduction of vertebral body and internal fixation. The patient was suggested to wear neck circumference external fixation for 3 months, and the function training of the cervical spine was performed according to the patient's recovery.\n\nFollow-up/imaging\nThe Neck Disability Index (NDI) score was 41 before the operation and 24 one year after the operation. The preoperative JOA score was 14, and the JOA score was 15 at 1 year after operation. The Cobb angle of C2–7 cervical lordosis was about 11° before the operation. The Cobb angle of C2–7 cervical lordosis was about 27° at 1 year after operation. The intervertebral height of the injured segment was about 2.6 mm before operation. The intervertebral height of the injured segment was about 4.4 mm at 1 year after operation. Compared with the preoperative image, the Cobb angle of C2–7 cervical lordosis, the intervertebral height of the injured segment, and the NDI score were significantly improved.", + "fulltext_subclaims": [ + "The patient was a 67-year-old male.", + "Six hours before arriving at the hospital, he suffered a car accident.", + "The car accident caused his persistent neck pain.", + "The car accident caused his neck to be unable to move.", + "There were no effective measures of pain relief.", + "There were no such accompanying symptoms as nausea, vomiting, dizziness, and headache.", + "The right side of the patient's neck was significantly swollen.", + "The trachea was shifted to the left.", + "The patient had no history of chronic diseases such as hypertension, diabetes, and coronary heart disease.", + "The Neck Disability Index (NDI), JOA score, operation time, intraoperative blood loss, and perioperative complications were recorded before and after the operation.", + "The improvement of the height of the injured intervertebral space was compared by imaging.", + "The situation of the reattachment of the facet joint was compared by imaging.", + "The improvement of the Cobb angle of the C2–7 cervical lordosis was compared by imaging.", + "The situation of interbody fusion was evaluated by imaging according to the modified Brantigan criteria.", + "Skull traction was performed immediately after admission.", + "The traction weight of the patient was 4–10 Kg.", + "The average traction weight was (6.0 ± 2.0) Kg.", + "The patient's neck arterial-venous CTA examination was immediately performed.", + "The result showed that did not find obvious contrast agent leakage.", + "After continuous skull traction, we reexamined the patient's neck CT.", + "It was confirmed that the locked facet joints of the patient had been reattached.", + "An elective operation of ACDF was performed on the injured segment of the cervical spine.", + "Intravenous inhalation combined with anesthesia was used during the operation.", + "The patient was placed in a supine position.", + "A right anterior cervical transverse incision was made about 5 cm in length.", + "The C-arm X-ray fluoroscopy was used to determine the intervertebral disc of the injured segment.", + "The target intervertebral disc was confirmed under direct vision.", + "The outer annulus fibrosus was incised with a sharp knife.", + "A spatula and nucleus pulposus forceps were used to completely remove the injured intervertebral disc from the endplate.", + "The bone graft beds on both sides of the endplate were repaired and rinsed with normal saline.", + "The size of the intervertebral fusion cage was determined.", + "The Cage loaded with autologous bone particles was inserted into the intervertebral space.", + "Through C-arm fluoroscopy, the Cage position was good.", + "The appropriate length of the anterior cervical titanium plate was selected.", + "The titanium plate was locked by locking screws.", + "The internal fixation position was determined to be satisfactory by fluoroscopy again.", + "The incision was washed with physiological saline.", + "A drainage tube was put in the incision before closing the incision.", + "After the operation, antibiotics, hormones, and dehydration drugs were routinely used for 4–5 days.", + "Atomization inhalation was performed for 3 days.", + "The drainage tube was removed 48–72 h after operation.", + "X-ray and CT were reexamined after the operation.", + "The patient was suggested to wear neck circumference external fixation for 3 months.", + "The function training of the cervical spine was performed according to the patient's recovery.", + "The Neck Disability Index (NDI) score was 41 before the operation.", + "The NDI score was 24 one year after the operation.", + "The preoperative JOA score was 14.", + "The JOA score was 15 at 1 year after operation.", + "The Cobb angle of C2–7 cervical lordosis was about 11° before the operation.", + "The Cobb angle of C2–7 cervical lordosis was about 27° at 1 year after operation.", + "The intervertebral height of the injured segment was about 2.6 mm before operation.", + "The intervertebral height of the injured segment was about 4.4 mm at 1 year after operation.", + "Compared with the preoperative image, the Cobb angle of C2–7 cervical lordosis was significantly improved.", + "Compared with the preoperative image, the intervertebral height of the injured segment was significantly improved.", + "Compared with the preoperative image, the NDI score was significantly improved." + ], + "summary": "The patient was a 67-year-old male patient. His chief complaint was that six hours before arriving at the hospital, he suffered a car accident which caused his persistent neck pain with no effective measures of pain relief and his neck could not move. There were no such accompanying symptoms as nausea, vomiting, dizziness, and headache. Physical examination showed that the patient's limbs had no obvious limitation of movement and no symptoms of nervous injury. However, the right side of the patient's neck was significantly swollen, and the trachea was shifted to the left, The patient had no history of chronic diseases such as hypertension, diabetes, and coronary heart disease.", + "summary_subclaims": [ + "The patient was a 67-year-old male patient.", + "Six hours before arriving at the hospital, he suffered a car accident.", + "The car accident caused his persistent neck pain.", + "There were no effective measures of pain relief.", + "His neck could not move.", + "There were no such accompanying symptoms as nausea, vomiting, dizziness, and headache.", + "Physical examination showed that the patient's limbs had no obvious limitation of movement.", + "There were no symptoms of nervous injury.", + "The right side of the patient's neck was significantly swollen.", + "The trachea was shifted to the left.", + "The patient had no history of chronic diseases such as hypertension, diabetes, and coronary heart disease." + ] + }, + { + "id": "multiclinsum_test_2513_en.txt", + "fulltext": "A 36-year-old male, right-handed, with no prior medical history, sustained a road traffic accident as a pedestrian struck by a vehicle. He was injured on the right side of his body. He was admitted immediately to our hospital. Upon arrival, he was conscious and hemodynamically stable. Clinical examination showed a visible deformity of his right arm with diffuse traumatic ecchymosis. There was pain, tenderness and an open wound over anterior aspect of the right shoulder measuring 5 cm with moderate soft tissue injury corresponding to grade II of the Gustilo classification. There was no distal neurovascular deficit. Radiographs indicated an anterior dislocation of the shoulder with ipsilateral transverse fracture of the middle third of the shaft humerus . Thus, the patient was urgently carried to the operating theatre. Under general anesthesia closed reduction of the shoulder dislocation was performed manually without difficulty. Then, the humeral shaft fracture was stabilized using Hackethal's bundle nailing after debridement of the wound . The right limb was immobilized in a plaster slab. The next day, the patient developed severe pain and swelling in the right arm and forearm, associated with paresthesia and loss of sensation in the hand. He was unable to flex all fingers. Furthermore, radial and ulnar pulses were present but weak. Therefore, the diagnosis of compartment syndrome was clinically obvious without measuring compartment pressures. The patient was returned to the operating room for decompression. Indeed, we performed a lazy S fasciotomy of the anterior aspect of the forearm and arm. The superficial fascia was released and the deep fascia was opened . Postoperatively, there was no drainage system and the limb was immobilized with a plaster splint. The pain was relieved after the fasciotomy, the neurologic functions were recovered, and the swelling was subsided. Whereas, the primary closure of the wounds was impossible after repeat surgical debridement with removal of devitalized tissues. Hence, skin grafting was performed on 10th day . The upper limb was immobilized for 3 weeks while the wound healed. A passive rehabilitation was undertaken. At 4-month follow-up, the bundle nailing was removed and radiographs revealed good fracture union. At the latest follow-up of 10 months, he had a useful range of motion compared with the contralateral limb with a slight restriction in elbow flexion. Additionally, the Constant score was approximately 80/100 and the patient had returned to normal activities.", + "fulltext_subclaims": [ + "The patient is a 36-year-old male.", + "The patient is right-handed.", + "The patient sustained a road traffic accident as a pedestrian struck by a vehicle.", + "The patient was injured on the right side of his body.", + "The patient was admitted immediately to the hospital.", + "Upon arrival, the patient was conscious.", + "Upon arrival, the patient was hemodynamically stable.", + "Clinical examination showed a visible deformity of the right arm.", + "There was diffuse traumatic ecchymosis.", + "There was pain, tenderness, and an open wound over the anterior aspect of the right shoulder.", + "The open wound measured 5 cm.", + "The wound had moderate soft tissue injury corresponding to grade II of the Gustilo classification.", + "There was no distal neurovascular deficit.", + "Radiographs indicated an anterior dislocation of the shoulder.", + "Radiographs indicated an ipsilateral transverse fracture of the middle third of the shaft humerus.", + "The patient was urgently carried to the operating theatre.", + "Closed reduction of the shoulder dislocation was performed manually.", + "The humeral shaft fracture was stabilized using Hackethal's bundle nailing.", + "The right limb was immobilized in a plaster slab.", + "The patient developed severe pain and swelling in the right arm and forearm.", + "The patient had paresthesia and loss of sensation in the hand.", + "The patient was unable to flex all fingers.", + "Radial and ulnar pulses were present but weak.", + "The diagnosis of compartment syndrome was clinically obvious.", + "The patient was returned to the operating room for decompression.", + "A lazy S fasciotomy of the anterior aspect of the forearm and arm was performed.", + "The superficial fascia was released.", + "The deep fascia was opened.", + "There was no drainage system postoperatively.", + "The limb was immobilized with a plaster splint.", + "The pain was relieved after the fasciotomy.", + "Neurologic functions were recovered.", + "The swelling was subsided.", + "Primary closure of the wounds was impossible after repeat surgical debridement.", + "Skin grafting was performed on the 10th day.", + "The upper limb was immobilized for 3 weeks.", + "A passive rehabilitation was undertaken.", + "At 4-month follow-up, the bundle nailing was removed.", + "Radiographs revealed good fracture union.", + "At the latest follow-up of 10 months, the patient had a useful range of motion.", + "The patient had a slight restriction in elbow flexion.", + "The Constant score was approximately 80/100.", + "The patient had returned to normal activities." + ], + "summary": "A 36-year-old male, sustained a road traffic accident as a pedestrian struck by a vehicle. He was diagnosed with an anterior dislocation of the right shoulder with an ipsilateral open transverse fracture of the middle third of the humeral shaft. He was treated with closed reduction and Hackethal bundle nailing. The next day, the patient developed acute compartment syndrome and underwent multiple fasciotomy.", + "summary_subclaims": [ + "The patient is a 36-year-old male.", + "He sustained a road traffic accident as a pedestrian struck by a vehicle.", + "He was diagnosed with an anterior dislocation of the right shoulder.", + "He was diagnosed with an ipsilateral open transverse fracture of the middle third of the humeral shaft.", + "He was treated with closed reduction.", + "He was treated with Hackethal bundle nailing.", + "The next day, the patient developed acute compartment syndrome.", + "He underwent multiple fasciotomy." + ] + }, + { + "id": "multiclinsum_test_660_en.txt", + "fulltext": "Our patient was a 27-year-old Javanese man with borderline intellectual functioning and striking dysmorphisms. Both his parents were Javanese, normal, non-consanguineous, and in their sixth decade of life. He was the third child born after a normal third pregnancy and he had two sisters who were normal. His mother had a cesarean delivery with no history of trauma, infection, or drug use during the term. No family history of similar complaints or any other congenital abnormality was reported. Our patient was born at term after an uneventful pregnancy.\nHe is a slow learner and attends a school for children with special needs in Cirebon, West Java, Indonesia. There he began to socialize, play with other classmates, and he likes to draw and enjoys music. The dysmorphisms found are very characteristic. On physical examination, his weight was 36 kg, height 158 cm, and occipital frontal circumference 54 cm. It was observed that he displayed hypertelorism, down-slanting palpebral fissure, strabismus, ocular proptosis, depressed nasal bridge, short philtrum, and low-set ears. In addition, acrocephaly, asymmetrical flat facies, nasal deformity, and prominent jaw were present . His oral deformities showed maxilla hypoplasia with high arch palate. His V-shaped maxillary arch was filled with double rows of teeth. In addition, there was a dental fusion between maxillary premolar and first molar. Panoramic radiographs were performed for confirmation . Other abnormalities found were mild scoliosis and mild pectus excavatum. Symmetrical cutaneous bilateral syndactyly involving his four fingers, his palms were spoon-shaped with an inwardly placed thumb, was present (type 2). Both feet showed type 2 symmetrical cutaneous syndactyly of the first to fifth toes. Radiographs of both hands and feet confirmed soft tissue syndactyly . He had corrective surgery twice on both hands to correct for joint contractures. There was no postoperative complication. Six months after the second surgery, he could start using his fingers. A clinical diagnosis of AS was previously made based on these clinical features, as earlier mentioned in our study describing clinical manifestations of this patient . Furthermore, Pictures of Standard Syndromes and Undiagnosed Malformations (POSSUM) software was used before molecular analysis and the result showed suspected AS with a cut-off point of 14. Ethical clearance for genetic testing was obtained according to the research ethic committee of Faculty of Medicine, Swadaya Gunung Jati University, Indonesia.\nMutation analysis was conducted for our patient. DNA was isolated from peripheral blood using the salt saturation method, as previously described by Miller et al. . Molecular genetics analysis of FGFR2, targeting exon 7, was performed by direct sequencing at the Laboratory of Neurovascular Unit and Cognitive Impairments, University of Poitiers, France. The reference genomic DNA sequence used was NM_000141.4. Polymerase chain reaction (PCR) amplification of exon 7 from the FGFR2 gene was performed using the primers FGFR2-F 5-CCGGCAGTCTCCTTTGAAGT-3′ and FGFR2-R 5′-GATCTGTTAATTCCTTAGAACACTCTCT-3′, resulting in a 525 bp fragment. Approximately 50 ng of DNA solution (2.5 μl) was added to 22.5 μl of PCR mixture. This PCR mixture contained 0.25 μl of 25 mM deoxyribonucleotide triphosphates (dNTPs), 3 μl of 25 mM MgCl2, 0.25 μl of each 20 μM primer, 2.5 μl of 10× PCR buffer, 0.125 μl of 5 U/μl Diamond® high fidelity Taq DNA polymerase (Eurogentec), and 16.13 μl of H2O. PCR was initiated with denaturation at 95 °C for 3 minutes, followed by 35 PCR cycles (at 95 °C for 30 seconds, 60 °C for 30 seconds, and 72 °C for 30 seconds) and 7 minutes final elongation at 72 °C. The amplified products were detected by electrophoresis on a 1.5% agarose gel with 0.5 mg/ml ethidium bromide and visualized under ultraviolet (UV) light. Furthermore, 5 μl of the PCR product was cleaned up with 2 μl ExoSAP reagent (ThermoFisher) according to the manufacturer’s instructions, to remove excess primers and unincorporated nucleotides enzymatically. Finally, 2 μl of the PCR product was used for the sequence reaction (BigDye Terminator Cycle Sequencing Kit Version 3.3; Applied Biosystems), which was run on an ABI PRISM® 310 Genetic Analyzer (Applied Biosystems), following the manufacturer’s directions. Sequencing was performed bidirectionally using the forward and reverse PCR primers. The sequence result was compared with the published reference sequence using Chromas software version 2.6.4. In this patient, we detected a missense mutation, changing a TCG codon (coding for a serine) into a TGG (coding for a tryptophan): p.Ser252Trp (c.755C>G) .", + "fulltext_subclaims": [ + "The patient was a 27-year-old Javanese man with borderline intellectual functioning and striking dysmorphisms.", + "Both his parents were Javanese, normal, non-consanguineous, and in their sixth decade of life.", + "He was the third child born after a normal third pregnancy.", + "He had two sisters who were normal.", + "His mother had a cesarean delivery with no history of trauma, infection, or drug use during the term.", + "No family history of similar complaints or any other congenital abnormality was reported.", + "The patient was born at term after an uneventful pregnancy.", + "He is a slow learner and attends a school for children with special needs in Cirebon, West Java, Indonesia.", + "On physical examination, his weight was 36 kg, height 158 cm, and occipital frontal circumference 54 cm.", + "He displayed hypertelorism, down-slanting palpebral fissure, strabismus, ocular proptosis, depressed nasal bridge, short philtrum, and low-set ears.", + "Acrocephaly, asymmetrical flat facies, nasal deformity, and prominent jaw were present.", + "His oral deformities showed maxilla hypoplasia with high arch palate.", + "His V-shaped maxillary arch was filled with double rows of teeth.", + "There was a dental fusion between maxillary premolar and first molar.", + "Panoramic radiographs were performed for confirmation.", + "Other abnormalities found were mild scoliosis and mild pectus excavatum.", + "Symmetrical cutaneous bilateral syndactyly involving his four fingers, his palms were spoon-shaped with an inwardly placed thumb, was present (type 2).", + "Both feet showed type 2 symmetrical cutaneous syndactyly of the first to fifth toes.", + "Radiographs of both hands and feet confirmed soft tissue syndactyly.", + "He had corrective surgery twice on both hands to correct for joint contractures.", + "There was no postoperative complication.", + "Six months after the second surgery, he could start using his fingers.", + "A clinical diagnosis of AS was previously made based on these clinical features.", + "Pictures of Standard Syndromes and Undiagnosed Malformations (POSSUM) software was used before molecular analysis and the result showed suspected AS with a cut-off point of 14.", + "Ethical clearance for genetic testing was obtained according to the research ethic committee of Faculty of Medicine, Swadaya Gunung Jati University, Indonesia.", + "Mutation analysis was conducted for our patient.", + "DNA was isolated from peripheral blood using the salt saturation method.", + "Molecular genetics analysis of FGFR2, targeting exon 7, was performed by direct sequencing at the Laboratory of Neurovascular Unit and Cognitive Impairments, University of Poitiers, France.", + "The reference genomic DNA sequence used was NM_000141.4.", + "PCR amplification of exon 7 from the FGFR2 gene was performed using the primers FGFR2-F 5-CCGGCAGTCTCCTTTGAAGT-3′ and FGFR2-R 5′-GATCTGTTAATTCCTTAGAACACTCTCT-3′, resulting in a 525 bp fragment.", + "Approximately 50 ng of DNA solution (2.5 μl) was added to 22.5 μl of PCR mixture.", + "The PCR mixture contained 0.25 μl of 25 mM deoxyribonucleotide triphosphates (dNTPs), 3 μl of 25 mM MgCl2, 0.25 μl of each 20 μM primer, 2.5 μl of 10× PCR buffer, 0.125 μl of 5 U/μl Diamond® high fidelity Taq DNA polymerase (Eurogentec), and 16.13 μl of H2O.", + "PCR was initiated with denaturation at 95 °C for 3 minutes, followed by 35 PCR cycles (at 95 °C for 30 seconds, 60 °C for 30 seconds, and 72 °C for 30 seconds) and 7 minutes final elongation at 72 °C.", + "The amplified products were detected by electrophoresis on a 1.5% agarose gel with 0.5 mg/ml ethidium bromide and visualized under ultraviolet (UV) light.", + "5 μl of the PCR product was cleaned up with 2 μl ExoSAP reagent (ThermoFisher) according to the manufacturer’s instructions.", + "2 μl of the PCR product was used for the sequence reaction (BigDye Terminator Cycle Sequencing Kit Version 3.3; Applied Biosystems), which was run on an ABI PRISM® 310 Genetic Analyzer (Applied Biosystems), following the manufacturer’s directions.", + "Sequencing was performed bidirectionally using the forward and reverse PCR primers.", + "The sequence result was compared with the published reference sequence using Chromas software version 2.6.4.", + "In this patient, we detected a missense mutation, changing a TCG codon (coding for a serine) into a TGG (coding for a tryptophan): p.Ser252Trp (c.755C>G)." + ], + "summary": "A 27-year-old Javanese man presented borderline intellectual functioning and striking dysmorphisms. A clinical diagnosis of Apert syndrome was previously made based on these clinical features. Furthermore, POSSUM software was used before molecular analysis and the result showed suspected Apert syndrome with a cut-off point of 14. Molecular genetic analysis of FGFR2, targeting exon 7, was performed by direct sequencing. In this patient, a missense mutation c.755C>G was detected, changing a serine into a tryptophan (p.Ser252Trp).", + "summary_subclaims": [ + "The patient is a 27-year-old Javanese man.", + "The patient had borderline intellectual functioning.", + "The patient had striking dysmorphisms.", + "A clinical diagnosis of Apert syndrome was previously made.", + "POSSUM software was used before molecular analysis.", + "The result of the POSSUM software showed suspected Apert syndrome.", + "The cut-off point used by the POSSUM software was 14.", + "Molecular genetic analysis of FGFR2 was performed.", + "Exon 7 of FGFR2 was targeted by the molecular genetic analysis.", + "Direct sequencing was used for the molecular genetic analysis.", + "A missense mutation c.755C>G was detected.", + "The mutation changes a serine into a tryptophan.", + "The mutation is p.Ser252Trp." + ] + }, + { + "id": "multiclinsum_test_241_en.txt", + "fulltext": "A 44-year-old female factory worker presented to our clinic complaining of a 1 year history of repeated, temporal and parietal headache characterized by bursting sensations. She had previously presented to a local hospital 6 months prior, in April 2016. The patient’s initial brain magnetic resonance imaging (MRI) and magnetic resonance angiography (MRA) were normal. CSF studies revealed 68 white cells per microliter and a pressure of 310 mmH2O. Viral encephalitis was suspected and she received acyclovir intravenously (500 mg Q8H for 7 days), but symptoms showed no signs of relief.\nThe patient visited the local hospital again 3 months later, in July 2016, complaining of an aggravated headache and paroxysmal numbness of her left face and arm. She was diagnosed with an ischemic stroke of the right thalamus and administered oral aspirin 100 mg and atorvastatin calcium 20 mg daily . Her numbness improved while the headache showed no improvement.\nShe visited the local hospital for the third time 5 days prior to presenting to our hospital due to the severity of her headache on October 26, 2016. Lumbar puncture was remarkable for a CSF pressure greater than 400 mmH2O, white cell count of 40 per microliter, and a protein level of 1171 mg/L. Cerebral magnetic resonance venography (MRV) revealed underdevelopment of her right lateral sinus and sinus thrombosis was considered as a possible etiology. She was treated with low molecular heparin and her headache was slightly relieved. She was then admitted to our hospital for further treatment.\nThe patient had no significant past medical history, denied a history of blood transfusions and consumption of raw food. Her physical examination was unremarkable, and no abnormal neurologic signs apart from horizontal nystagmus was noted.\nLaboratory tests revealed the proportion of eosinophils to be slightly elevated (3.35%) while other indices were within normal limits. HIV, syphilis, and Herpes simplex virus-1 and 2 antibodies were absent. In addition, the T-Cell spot test, purified protein derivative test for Mycobacillus Tuberclosis and Latex agglutination test for the cryptococcal capsular antigen were all negative. She underwent three lumbar punctures after admission to our clinic and results revealed a high intracranial pressure and an increased white cell count .\nNo abnormalities were found on cerebral MRA, while MRV imaging suggested underdevelopment of the right lateral sinus. Digital subtraction angiography (DSA) revealed the arterial system to be normal and confirmed dysplasia of the right lateral sinus . Cerebral MRI with contrast revealed several small, hyperintense lesions involving the right cerebellar hemisphere and bilateral occipital lobe, with gadolinium ring enhancement . NGS of CSF sample was further carried out and suggested several possible pathogens including parasites and virus . Serum was subsequently evaluated for presence of cysticercal antibodies and CSF also confirmed positivity, but negative for Echinococcus granulosus. Review of the patient’s previous imaging records revealed several additional anomalies: her pulmonary CT revealed multiple densities in chest wall soft tissue , and her chest radiographs take 6 months prior to admission to our hospital revealed multiple calcifications on the left side of the neck and right chest wall . A diagnosis of cerebral cysticercosis was therefore finally established. Oral praziquantel (2.5 mg/Kg/d × 7 days for one procedure) was administered thrice. Her headache was recovered markedly. Three months after she was discharged, her secondary cranial MR scan revealed persistence of the aforementioned ring-enhancing lesions . She underwent a repeat lumber puncture that revealed a CSF pressure of 220 mmH2O and 10 white blood cells per microliter. Meanwhile, CSF cysticercal antibodies remained positive. Repeat CSF NGS revealed that the T. solium index dropped considerably compared to initial NGS readings. On follow-up 6 months later, she reported no persisting symptoms.\nCSF was collected via standard procedures. DNA was extracted from 300 μL CSF samples using the TIANamp Micro DNA Kit (DP316, Tiangen Biotech, Beijing, China) and sonicated to a size of 200–300 bps fragments (Bioruptor Pico protocols). DNA libraries were then constructed via end-repaired adaptation added overnight and application of polymerase chain reaction (PCR) amplification to extracted DNA. An Agilent 2100 Bio-analyzer (Agilent Technologies, Santa Clara, CA) in combination with quantitative PCR was utilized to quantify DNA libraries. Sequencing was performed using the BGISEQ-100 platform (BGI-Tianjin, Tianjin, China) .\nMost high-quality sequencing data were generated and computational subtraction of human host sequences was performed using a Burrows- Wheeler Alignment tool . Remaining sequencing data were aligned with Microbial Genome Databases, which is composed of 2700 whole genome sequences of viral taxa, 1494 bacterial genomes or scaffolds, 73 fungi and 47 parasites associated with human infectivity. The total number of reads from different samples was standardized as 20 M for comparison. After alignment, previously obtained files were filtered and duplicates removed. ThMmapped data were further processed and with the depth and coverage of each species calculated using Soap Coverage . A control sample from a non-infected patient was obtained and subjected to the aforementioned procedures. The DNA of CSF samples before and after drug treatment was extracted to construct a complementary DNA (cDNA) library for sequencing. The number of reads from the cDNA library of the patient’s CSF was 37,781,754 (before drug treatment) and 19,043,412 (after drug treatment) respectively. Those of the control sample were 25,962,600. As a result of pathogen detection, T.solium was identified as the most predominant parasite with 3.495% coverage of the T.solium genome in the first detection; however this reduced to 0.078% in the second detection after specific drug therapy. No reads of T.solium were detected from control samples. Reads of viruses were also detected in the CSF samples, later identified as human herpesvirus 4 (HHV-4). After drug therapy, the number of HHV-4 reads decreased approximately 20-fold. The results of CSF NGS prior to and after praziquantel therapy are shown in Table .", + "fulltext_subclaims": [ + "The patient is a 44-year-old female factory worker.", + "She had a 1 year history of repeated, temporal and parietal headache characterized by bursting sensations.", + "She had previously presented to a local hospital 6 months prior, in April 2016.", + "The patient’s initial brain MRI and MRA were normal.", + "CSF studies revealed 68 white cells per microliter and a pressure of 310 mmH2O.", + "Viral encephalitis was suspected.", + "She received acyclovir intravenously (500 mg Q8H for 7 days).", + "Symptoms showed no signs of relief.", + "She visited the local hospital again 3 months later, in July 2016.", + "She was diagnosed with an ischemic stroke of the right thalamus.", + "She was administered oral aspirin 100 mg and atorvastatin calcium 20 mg daily.", + "Her numbness improved.", + "The headache showed no improvement.", + "She visited the local hospital for the third time 5 days prior to presenting to our hospital due to the severity of her headache on October 26, 2016.", + "Lumbar puncture was remarkable for a CSF pressure greater than 400 mmH2O.", + "Cerebral MRV revealed underdevelopment of her right lateral sinus.", + "Sinus thrombosis was considered as a possible etiology.", + "She was treated with low molecular heparin.", + "Her headache was slightly relieved.", + "She was admitted to our hospital for further treatment.", + "The patient had no significant past medical history.", + "She denied a history of blood transfusions and consumption of raw food.", + "Her physical examination was unremarkable.", + "No abnormal neurologic signs apart from horizontal nystagmus was noted.", + "Laboratory tests revealed the proportion of eosinophils to be slightly elevated (3.35%).", + "HIV, syphilis, and Herpes simplex virus-1 and 2 antibodies were absent.", + "The T-Cell spot test, purified protein derivative test for Mycobacillus Tuberclosis, and Latex agglutination test for the cryptococcal capsular antigen were all negative.", + "She underwent three lumbar punctures after admission to our clinic.", + "Results revealed a high intracranial pressure and an increased white cell count.", + "No abnormalities were found on cerebral MRA.", + "MRV imaging suggested underdevelopment of the right lateral sinus.", + "DSA revealed the arterial system to be normal.", + "DSA confirmed dysplasia of the right lateral sinus.", + "Cerebral MRI with contrast revealed several small, hyperintense lesions involving the right cerebellar hemisphere and bilateral occipital lobe.", + "Cerebral MRI with contrast revealed gadolinium ring enhancement.", + "NGS of CSF sample was further carried out.", + "NGS suggested several possible pathogens including parasites and virus.", + "Serum was evaluated for presence of cysticercal antibodies.", + "CSF also confirmed positivity.", + "CSF was negative for Echinococcus granulosus.", + "Review of the patient’s previous imaging records revealed multiple densities in chest wall soft tissue on pulmonary CT.", + "Chest radiographs taken 6 months prior to admission revealed multiple calcifications on the left side of the neck and right chest wall.", + "A diagnosis of cerebral cysticercosis was finally established.", + "Oral praziquantel (2.5 mg/Kg/d × 7 days for one procedure) was administered thrice.", + "Her headache was recovered markedly.", + "Three months after discharge, her secondary cranial MR scan revealed persistence of the aforementioned ring-enhancing lesions.", + "She underwent a repeat lumbar puncture.", + "CSF pressure was 220 mmH2O.", + "CSF revealed 10 white blood cells per microliter.", + "CSF cysticercal antibodies remained positive.", + "Repeat CSF NGS revealed that the T. solium index dropped considerably compared to initial NGS readings.", + "On follow-up 6 months later, she reported no persisting symptoms.", + "CSF was collected via standard procedures.", + "DNA was extracted from 300 μL CSF samples using the TIANamp Micro DNA Kit.", + "DNA was sonicated to a size of 200–300 bps fragments.", + "DNA libraries were constructed via end-repaired adaptation added overnight.", + "PCR amplification was applied to extracted DNA.", + "An Agilent 2100 Bio-analyzer was used in combination with quantitative PCR to quantify DNA libraries.", + "Sequencing was performed using the BGISEQ-100 platform.", + "Most high-quality sequencing data were generated.", + "Computational subtraction of human host sequences was performed using the Burrows-Wheeler Alignment tool.", + "Remaining sequencing data were aligned with Microbial Genome Databases.", + "The total number of reads from different samples was standardized as 20 M for comparison.", + "After alignment, previously obtained files were filtered and duplicates removed.", + "Mapped data were further processed.", + "The depth and coverage of each species were calculated using Soap Coverage.", + "A control sample from a non-infected patient was obtained.", + "The control sample was subjected to the aforementioned procedures.", + "DNA of CSF samples before and after drug treatment was extracted to construct a cDNA library for sequencing.", + "The number of reads from the cDNA library of the patient’s CSF was 37,781,754 before drug treatment.", + "The number of reads from the cDNA library of the patient’s CSF was 19,043,412 after drug treatment.", + "The number of reads from the control sample was 25,962,600.", + "As a result of pathogen detection, T. solium was identified as the most predominant parasite.", + "T. solium had 3.495% coverage of the T. solium genome in the first detection.", + "This reduced to 0.078% in the second detection after specific drug therapy.", + "No reads of T. solium were detected from control samples.", + "Reads of viruses were also detected in the CSF samples.", + "These were later identified as human herpesvirus 4 (HHV-4).", + "After drug therapy, the number of HHV-4 reads decreased approximately 20-fold." + ], + "summary": "This study reports the clinical, imaging, and immunological features of a patient initially presenting with several months of headache who further developed a pure sensory stroke. NGS was used to detect the pathogen, and her CSF demonstrated the presence of Taenia solium-DNA. This finding was confirmed by a positive reaction to CSF cysticercosis antibodies. After antiparasitic treatment, secondary CSF NGS revealed the DNA index have dropped considerably compared to the initial NGS readings.", + "summary_subclaims": [ + "This study reports the clinical, imaging, and immunological features of a patient.", + "The patient initially presented with several months of headache.", + "The patient further developed a pure sensory stroke.", + "NGS was used to detect the pathogen.", + "The patient's CSF demonstrated the presence of Taenia solium-DNA.", + "This finding was confirmed by a positive reaction to CSF cysticercosis antibodies.", + "After antiparasitic treatment, secondary CSF NGS revealed the DNA index have dropped considerably compared to the initial NGS readings." + ] + }, + { + "id": "multiclinsum_test_2053_en.txt", + "fulltext": "A 24-year-old woman with cystinosis complicated by end-stage renal failure, for which she was receiving intermittent haemodialysis, was admitted with generalized malaise and weight loss. In May 2001, she had undergone trans-thoracic echocardiography because of increasing shortness of breath on exertion, and this had shown a moderately dilated LV with globally reduced systolic function (ejection fraction, EF = 25%), consistent with dilated cardiomyopathy.\nThe patient was referred for cardiology consultation following a period of increased breathlessness and a cardiac arrest precipitated by ventricular tachycardia from which she was successfully DC cardioverted. Her medication at that time included perindopril 4 mg once daily (od), carvedilol 3.125 mg twice daily (bd), prednisolone 5 mg od, levothyroxine 200 mcg od, folic acid 5 mg od, darbepoetin 80 mcg per week, mercaptamine (Cystagon) 150 mg four times per day (qds), calcium carbonate 500 mg three times daily (tds), aspirin 75 mg od and alfacalcidol 1.5 mcg od.\nOn examination, the patient's blood pressure was 86/50 mmHg and she was in sinus rhythm at 76 bpm. She had some facial oedema, mild ankle oedema and bi-basal crackles on chest auscultation. Heart sounds examination revealed a soft apical pansystolic murmur. The remainder of the examination was unremarkable. Echocardiography revealed a dilated LV with globally impaired systolic LV function (EF Simpsons biplane = 25%). There was marked trabeculation of the LV, most prominent at the apex and lateral wall at the mid-ventricular level; six trabeculae were more than 2 mm in diameter. The noncompacted to compacted ratio was 2.2 at the thickest part of the lateral wall on the parasternal short-axis view. Multiple inter-trabecular recesses in communication with the LV cavity were demonstrated by forward and reverse flow of blood on colour flow mapping . These features are consistent with current diagnostic criteria for isolated ventricular noncompaction. At the time of writing, the patient had been referred for heart and kidney transplant assessment and had undergone implantation of an automatic implantable cardioverter defibrillator (AICD).", + "fulltext_subclaims": [ + "The patient is a 24-year-old woman.", + "She has cystinosis.", + "She has end-stage renal failure.", + "She was receiving intermittent haemodialysis.", + "She was admitted with generalized malaise.", + "She was admitted with weight loss.", + "In May 2001, she had undergone trans-thoracic echocardiography.", + "The echocardiography had shown a moderately dilated LV.", + "The echocardiography had shown globally reduced systolic function.", + "The ejection fraction was 25%.", + "The findings were consistent with dilated cardiomyopathy.", + "She had a cardiac arrest precipitated by ventricular tachycardia.", + "She was successfully DC cardioverted.", + "Her medication included perindopril 4 mg once daily.", + "Her medication included carvedilol 3.125 mg twice daily.", + "Her medication included prednisolone 5 mg once daily.", + "Her medication included levothyroxine 200 mcg once daily.", + "Her medication included folic acid 5 mg once daily.", + "Her medication included darbepoetin 80 mcg per week.", + "Her medication included mercaptamine 150 mg four times per day.", + "Her medication included calcium carbonate 500 mg three times daily.", + "Her medication included aspirin 75 mg once daily.", + "Her medication included alfacalcidol 1.5 mcg once daily.", + "On examination, her blood pressure was 86/50 mmHg.", + "She was in sinus rhythm at 76 bpm.", + "She had some facial oedema.", + "She had mild ankle oedema.", + "Bi-basal crackles were heard on chest auscultation.", + "Heart sounds examination revealed a soft apical pansystolic murmur.", + "Echocardiography revealed a dilated LV.", + "Echocardiography revealed globally impaired systolic LV function.", + "The ejection fraction was 25%.", + "There was marked trabeculation of the LV.", + "The trabeculation was most prominent at the apex and lateral wall at the mid-ventricular level.", + "Six trabeculae were more than 2 mm in diameter.", + "The noncompacted to compacted ratio was 2.2 at the thickest part of the lateral wall.", + "Multiple inter-trabecular recesses were demonstrated by forward and reverse flow of blood on colour flow mapping.", + "These features are consistent with current diagnostic criteria for isolated ventricular noncompaction.", + "The patient had been referred for heart and kidney transplant assessment.", + "The patient had undergone implantation of an automatic implantable cardioverter defibrillator." + ], + "summary": "Our patient presented with an episode of decompensated heart failure. Trans-thoracic echocardiography demonstrated excessive trabeculation with inter-trabecular recesses in the left ventricle typical of noncompaction of the left ventricle. The patient's admission was complicated by a cardiac arrest precipitated by ventricular tachycardia for which she subsequently underwent implantation of an automatic implantable cardioverter defibrillator.", + "summary_subclaims": [ + "The patient presented with an episode of decompensated heart failure.", + "Trans-thoracic echocardiography demonstrated excessive trabeculation with inter-trabecular recesses in the left ventricle.", + "The echocardiographic findings were typical of noncompaction of the left ventricle.", + "The patient's admission was complicated by a cardiac arrest precipitated by ventricular tachycardia.", + "The patient underwent implantation of an automatic implantable cardioverter defibrillator." + ] + }, + { + "id": "multiclinsum_test_641_en.txt", + "fulltext": "The patient was a 45-year-old Asian (Japanese) woman, who presented polycystic ovarian syndrome, hypertension, hyper-urinary acid, bladder stone, urinary stone, progressive renal dysfunction, and lipid abnormality. When she was 3 years old, she visited our hospital because of hypoglycemia, liver enzyme elevation, and hepatomegaly. She was diagnosed as having GSD type Ia based on the loss of G6Pase activity in the liver (< 0.3 µmol/minute/g tissue).\nIn the first stage of life (3 years to 6 years), she needed frequent feedings and a night time cornstarch regimen until 7 years of age. After 8 years of age, her hypoglycemia improved and her glucose levels could be maintained with cornstarch intake twice a day. However, she had several complications such as kidney stones and hepatic adenomas with hepatomegaly.\nAt 20 years of age, her BMI increased (to 24.2) and she presented hyperglycemia after food intake . The blood glucose dynamics indicated type 2 diabetes mellitus as described in Fig. [Fasting glucose: 123 mg/dl, homeostatic model assessment of insulin resistance (HOMA-IR) 9.23]. Therefore, cornstarch feeding at night was stopped.\nAt 40 years of age, she presented hyperglycemia (200–260 mg/dl after feeding and dumping syndrome-like symptoms such as nausea, general fatigue, and dorsal pain). Moreover, the dumping syndrome-like symptoms worsened, resulting in poor quality of life. At first, she misunderstood that the complication was related to hypoglycemia and thus increased feeding, leading to an increase in body weight (maximum BMI was 26.4). Laboratory tests indicated elevated triglycerides (880 mg/dl) and abnormal liver function tests . Magnetic resonance imaging (MRI) of the abdomen revealed multiple liver adenomas with diffuse steatosis. Investigation of diabetes showed an insulin level of 68 µIU/ml (normal range: ≦ 18.7 µIU/ml), with fasting blood glucose levels of 126 mg/dl (normal range: 70–114 mg/dl). HOMA IR was calculated as 22.1 (N < 2.5), indicating severe insulin resistance.\nAt first, she attempted lifestyle modifications such as a lower carbohydrate diet, elongation of feeding time, and exercise. However, her condition did not improve. To avoid severe hypoglycemia and improve liver function, she was experimentally treated with luseogliflozin hydrate additionally, an SGLT2 inhibitor, at a dose of 2.5 mg daily, after obtaining informed consent. After this intervention, she decreased her cornstarch intake, and her dumping syndrome-like symptoms disappeared completely. In addition, her body weight (BMI 21) and insulin resistance both decreased remarkably (HOMA-IR 4.49; Fig. ).", + "fulltext_subclaims": [ + "The patient was a 45-year-old Asian (Japanese) woman.", + "She presented polycystic ovarian syndrome.", + "She had hypertension.", + "She had hyper-urinary acid.", + "She had bladder stone.", + "She had urinary stone.", + "She had progressive renal dysfunction.", + "She had lipid abnormality.", + "When she was 3 years old, she visited our hospital because of hypoglycemia.", + "When she was 3 years old, she had liver enzyme elevation.", + "When she was 3 years old, she had hepatomegaly.", + "She was diagnosed as having GSD type Ia based on the loss of G6Pase activity in the liver (< 0.3 µmol/minute/g tissue).", + "In the first stage of life (3 years to 6 years), she needed frequent feedings.", + "In the first stage of life (3 years to 6 years), she had a night time cornstarch regimen until 7 years of age.", + "After 8 years of age, her hypoglycemia improved.", + "After 8 years of age, her glucose levels could be maintained with cornstarch intake twice a day.", + "She had several complications such as kidney stones.", + "She had hepatic adenomas with hepatomegaly.", + "At 20 years of age, her BMI increased (to 24.2).", + "At 20 years of age, she presented hyperglycemia after food intake.", + "The blood glucose dynamics indicated type 2 diabetes mellitus.", + "Fasting glucose was 123 mg/dl.", + "HOMA-IR was 9.23.", + "Cornstarch feeding at night was stopped.", + "At 40 years of age, she presented hyperglycemia (200–260 mg/dl after feeding).", + "She had dumping syndrome-like symptoms such as nausea, general fatigue, and dorsal pain.", + "The dumping syndrome-like symptoms worsened, resulting in poor quality of life.", + "She misunderstood that the complication was related to hypoglycemia.", + "She increased feeding, leading to an increase in body weight.", + "Her maximum BMI was 26.4.", + "Laboratory tests indicated elevated triglycerides (880 mg/dl).", + "Abnormal liver function tests were noted.", + "MRI of the abdomen revealed multiple liver adenomas with diffuse steatosis.", + "Insulin level was 68 µIU/ml.", + "Fasting blood glucose levels were 126 mg/dl.", + "HOMA IR was calculated as 22.1.", + "She attempted lifestyle modifications such as a lower carbohydrate diet.", + "She attempted elongation of feeding time.", + "She attempted exercise.", + "Her condition did not improve.", + "She was experimentally treated with luseogliflozin hydrate, an SGLT2 inhibitor, at a dose of 2.5 mg daily.", + "She decreased her cornstarch intake.", + "Her dumping syndrome-like symptoms disappeared completely.", + "Her body weight decreased (BMI 21).", + "Her insulin resistance decreased remarkably.", + "HOMA-IR was 4.49." + ], + "summary": "The patient was a 45-year old Asian (Japanese) woman who showed disease onset at 3 years of age, when hypoglycemia and hepatomegaly were observed, and GDS type Ia was diagnosed by the lack of G6Pase activity. Over the past 45 years, she presented hyperglycemia and dumping syndrome like symptoms (a feeling of fullness, even after eating just a small amount, abdominal cramping, nausea, sweating, flushing, or light-headedness and rapid heartbeat) at 2 hours after food intake. Her liver and kidney dysfunction also worsened over time. Treatment with exercise combined with a sodium-glucose co-transporter 2 inhibitor and an alpha glucosidase inhibitor alleviated her glucose intolerance and dumping syndrome-like symptoms, without increasing hypoglycemic events.", + "summary_subclaims": [ + "The patient was a 45-year old Asian (Japanese) woman.", + "She showed disease onset at 3 years of age.", + "Hypoglycemia and hepatomegaly were observed at disease onset.", + "GDS type Ia was diagnosed by the lack of G6Pase activity.", + "Over the past 45 years, she presented hyperglycemia.", + "She presented dumping syndrome like symptoms at 2 hours after food intake.", + "Her liver and kidney dysfunction also worsened over time.", + "Treatment with exercise combined with a sodium-glucose co-transporter 2 inhibitor and an alpha glucosidase inhibitor alleviated her glucose intolerance.", + "Treatment alleviated her dumping syndrome-like symptoms.", + "Treatment did not increase hypoglycemic events." + ] + }, + { + "id": "multiclinsum_test_1844_en.txt", + "fulltext": "A 33-year-old Japanese woman first visited Okayama University Hospital in February, 2011 to evaluate numbness in her bilateral lower limbs, a condition that had developed since the age of 29, when she had a cervical spinal cord injury due to a car accident. The patient had no other previous medical history.\nGeneral medical and neurological examinations showed no other particular findings except for decreased vibration sensation and increased tendon reflexes in her bilateral lower limbs, which were present 4 years after the car accident.\nBiochemical blood tests showed no abnormal findings. A brain MRI revealed no lesion in fluid-attenuated inversion recovery (FLAIR; Figure A-D). However, a brain magnetic resonance angiography (MRA) incidentally found a 3.7 × 3.3 mm unruptured cerebral aneurysm (CAn) in her basilar artery located at the origin of the right superior cerebellar artery . When approximately 80 mL of nondiluted iopamidol (Iopamiron, Bayer Healthcare Inc., Leverkusen, Germany) was intravenously injected as the contrast medium (CM), a computed tomographic angiography (CTA) confirmed the CAn. An MRI revealed a small old lesion in the C5/6 level of the spinal cord, which was responsible for her leg symptoms. With extensive informed consent, endovascular coil embolization was performed through the right femoral artery under general anesthesia in which the patient became fully heparinized by 4,000 units of heparin sodium. Approximately 70 mL of nondiluted iopamidol was used throughout the procedure, distributed in one rotational acquisition of 14 mL as 10 standard vertebral injections of 5 mL each (to monitor parent vessel patency and aneurysm occlusion). The aneurysm was framed with a Microplex-10 complex 3/7 coil (Terumo, Isehara, Japan) and filled with 2 Micrus Deltaplush (Micrus Endovascular, San Jose, CA) coils. A HyperForm 4 × 7 balloon (Micro Therapeutics Inc, Irvine, CA) was intermittently inflated and deflated between coil placements. Postcoiling contrast angiography showed complete obliteration of the aneurysm . During the procedure, CM was injected only into the right vertebral artery. The right groin was closed by manual compression. There were almost no changes in vital signs such as blood pressure, heart rate, and respiratory rate during and after the operation. The patient awoke from anesthesia neurologically intact and was discharged from the hospital 72 hours after coiling.\nAlthough the patient did not develop any clinical symptoms, a follow-up brain MRI at 1 month showed several white matter lesions in the left cerebellar, bilateral occipitotemporal and left parietoccipital lobe without a positive signal in the diffusion-weighted image (DWI; Figure H-O, arrowheads). A further follow-up MRI at 2 months after coiling revealed the enlargement of each lesion , although she did not show any symptoms such as visual disturbance. Thus, she was re-admitted to our hospital for a detailed examination in July, 2011. However, blood and cerebrospinal fluid (CSF) biochemical tests showed no abnormal findings.\nAt 4 months, 2-deoxy-2-[F-18]fluoro-D-glucose (FDG) and 11C-methionine (MET) PET studies showed that glucose uptake in the lesion with areas enhanced by gadolinium-enhanced MRI (Gd-MRI; Figure E-H, arrowheads) increased slightly or remained at the baseline level , while methionine uptake increased . 1H-MRS showed a slight increase in the choline (cho) peak with a mean cho/creatine (cr) ratio of 1.10 versus 0.89 in the control. The mean N-acetylaspartate (NAA) peak was reduced with a mean NAA/cr ratio of 1.29 versus 2.34 in the control. An elevated lactate peak was also noted .\nA follow-up MRI at 6 and 12 months showed a gradual decrease in the initial hyperintense lesions in the left cerebellar, bilateral occipitotemporal and left parietoccipital lobe .", + "fulltext_subclaims": [ + "The patient is a 33-year-old Japanese woman.", + "She first visited Okayama University Hospital in February, 2011.", + "She had numbness in her bilateral lower limbs.", + "The numbness had developed since the age of 29.", + "She had a cervical spinal cord injury due to a car accident at the age of 29.", + "General medical and neurological examinations showed decreased vibration sensation in her bilateral lower limbs.", + "General medical and neurological examinations showed increased tendon reflexes in her bilateral lower limbs.", + "The decreased vibration sensation and increased tendon reflexes were present 4 years after the car accident.", + "Biochemical blood tests showed no abnormal findings.", + "A brain MRI revealed no lesion in fluid-attenuated inversion recovery (FLAIR).", + "A brain magnetic resonance angiography (MRA) found a 3.7 × 3.3 mm unruptured cerebral aneurysm in her basilar artery.", + "The aneurysm was located at the origin of the right superior cerebellar artery.", + "Computed tomographic angiography (CTA) confirmed the cerebral aneurysm.", + "An MRI revealed a small old lesion in the C5/6 level of the spinal cord.", + "Endovascular coil embolization was performed through the right femoral artery.", + "The procedure was performed under general anesthesia.", + "The patient became fully heparinized by 4,000 units of heparin sodium.", + "Approximately 70 mL of nondiluted iopamidol was used throughout the procedure.", + "The aneurysm was framed with a Microplex-10 complex 3/7 coil.", + "The aneurysm was filled with 2 Micrus Deltaplush coils.", + "A HyperForm 4 × 7 balloon was intermittently inflated and deflated between coil placements.", + "Postcoiling contrast angiography showed complete obliteration of the aneurysm.", + "CM was injected only into the right vertebral artery.", + "The right groin was closed by manual compression.", + "There were almost no changes in vital signs during and after the operation.", + "The patient awoke from anesthesia neurologically intact.", + "She was discharged from the hospital 72 hours after coiling.", + "A follow-up brain MRI at 1 month showed several white matter lesions in the left cerebellar, bilateral occipitotemporal, and left parietoccipital lobe.", + "The white matter lesions showed no positive signal in the diffusion-weighted image.", + "A follow-up MRI at 2 months after coiling revealed the enlargement of each lesion.", + "The patient did not show any symptoms such as visual disturbance.", + "She was re-admitted to the hospital in July, 2011.", + "Blood and cerebrospinal fluid biochemical tests showed no abnormal findings.", + "At 4 months, FDG PET showed that glucose uptake in the lesion with areas enhanced by Gd-MRI increased slightly or remained at the baseline level.", + "At 4 months, MET PET showed that methionine uptake increased.", + "1H-MRS showed a slight increase in the choline peak.", + "The mean cho/creatine ratio was 1.10 in the lesion.", + "The mean NAA peak was reduced.", + "The mean NAA/creatine ratio was 1.29 in the lesion.", + "An elevated lactate peak was noted.", + "A follow-up MRI at 6 months showed a gradual decrease in the initial hyperintense lesions.", + "A follow-up MRI at 12 months showed a gradual decrease in the initial hyperintense lesions." + ], + "summary": "A 33-year-old woman presented an incidental 3.7 × 3.3-mm unruptured cerebral aneurysm (CAn) in her basilar artery, which was successfully coiled with balloon assistance. A follow-up brain MRI at 1 and 2 months showed a gradual increase in several white matter hyperintense lesions in the left cerebellar, bilateral occipitotemporal and left parietoccipital lobe during fluid-attenuated inversion recovery (FLAIR). These were the only lesions associated with perfused CAn. However, the patient did not show any additional symptoms such as visual disturbance throughout the entire course. (11)C-methionine-PET (MET-PET) showed an obvious increase in methionine uptake in the lesion corresponding to enhanced areas with gadolinium-enhanced MRI. MRS showed a decrease in the N-acetylaspartate/creatine (NAA/cr) ratio and a slight elevation of the choline/creatine (cho/cr) ratio and a lactate peak in the lesion. A follow-up MRI at 6 and 12 months showed a gradual decrease in the initial hyperintense lesions in FLAIR without any treatment.", + "summary_subclaims": [ + "The patient was a 33-year-old woman.", + "She had an incidental 3.7 × 3.3-mm unruptured cerebral aneurysm in her basilar artery.", + "The aneurysm was successfully coiled with balloon assistance.", + "A follow-up brain MRI at 1 and 2 months showed a gradual increase in several white matter hyperintense lesions.", + "The lesions were in the left cerebellar, bilateral occipitotemporal, and left parietoccipital lobe during FLAIR.", + "These were the only lesions associated with perfused CAn.", + "The patient did not show any additional symptoms such as visual disturbance.", + "(11)C-methionine-PET showed an obvious increase in methionine uptake in the lesion corresponding to enhanced areas with gadolinium-enhanced MRI.", + "MRS showed a decrease in the N-acetylaspartate/creatine (NAA/cr) ratio.", + "MRS showed a slight elevation of the choline/creatine (cho/cr) ratio.", + "MRS showed a lactate peak in the lesion.", + "A follow-up MRI at 6 and 12 months showed a gradual decrease in the initial hyperintense lesions in FLAIR.", + "There was no treatment." + ] + }, + { + "id": "multiclinsum_test_1547_en.txt", + "fulltext": "Our patient was a 74-year-old woman, without any particular pathological antecedents, presenting intermittent and badly systemized bilateral sciatica, along with weaknesses in both lower limbs, gradually progressing for 2 years. This symptomatology got complicated by sphincter disorders characterized by urinary incontinence and constipation. The clinical examination objectified incomplete paraplegia without sensory loss. Patellar and Achilles reflexes were reduced on both the lower limbs. MRI showed an intradural fusiform lesion at L3–L4, with an isosignal on T1 and T2, associated with a central nodular hypersignal on both sequences. The lesion took up the whole spinal canal, making a scallop shape on the vertebral body and laminating its posterior arch. The tumor homogenously enhanced following a gadolinium injection . The diagnosis for neurinoma was highly suspected. Through an L3 and L4 laminectomy and an opening of the dura mater, the tumor appeared to be grayish red, closed, very hemorrhagic, and tied to the filum terminale. The lesion retracted nerve roots on the back and on the left side without any invasion. The tumor was attached to the filum terminal and his section has facilitated total removal. The patient fully recovered her motor function after a sphincter and motor function rehabilitation. Macroscopically, the anatomopathological examination showed an encapsulated proliferative tumor, lobulated and surrounded by tiny fiber tracts. It was vascularized with large plaques of hemorrhagic suffusion. Microscopically, we showed lobulated cells with eosinophilic cytoplasms, sharply demarcated, with dense and rounded nuclei, pointing in immunohistochemistry neuron-specific enolase (NSE) and chromogranin A (CgA) .", + "fulltext_subclaims": [ + "The patient was a 74-year-old woman.", + "The patient had intermittent and badly systemized bilateral sciatica.", + "The patient had weaknesses in both lower limbs.", + "The symptomatology had been gradually progressing for 2 years.", + "The symptomatology was complicated by sphincter disorders.", + "The clinical examination objectified incomplete paraplegia without sensory loss.", + "Patellar and Achilles reflexes were reduced on both the lower limbs.", + "MRI showed an intradural fusiform lesion at L3–L4.", + "The lesion had an isosignal on T1 and T2.", + "The lesion had a central nodular hypersignal on both sequences.", + "The lesion took up the whole spinal canal.", + "The tumor homogenously enhanced following a gadolinium injection.", + "The diagnosis for neurinoma was highly suspected.", + "The tumor was grayish red, closed, very hemorrhagic, and tied to the filum terminale.", + "The tumor retracted nerve roots on the back and on the left side without any invasion.", + "The tumor was attached to the filum terminal.", + "The patient fully recovered her motor function after a sphincter and motor function rehabilitation.", + "Macroscopically, the anatomopathological examination showed an encapsulated proliferative tumor.", + "The tumor was lobulated and surrounded by tiny fiber tracts.", + "The tumor was vascularized with large plaques of hemorrhagic suffusion.", + "Microscopically, lobulated cells with eosinophilic cytoplasms were observed.", + "The nuclei were dense and rounded.", + "Immunohistochemistry pointed to neuron-specific enolase (NSE) and chromogranin A (CgA)." + ], + "summary": "We report a case of paraganglioma of the filum terminale in a 74-year-old female patient, admitted for cauda equina syndrome, which has been progressing for 2 years. MRI of medulla objectified an extramedullary lesion at L3-L4, diagnosed as neurinoma. A complete resection of the tumor was performed with a section of the filum terminale, which she was taking since birth. Histology confirmed the diagnosis of paraganglioma. The clinical course was characterized by a complete recovery of the deficit.", + "summary_subclaims": [ + "The patient is a 74-year-old female.", + "The patient was admitted for cauda equina syndrome.", + "The cauda equina syndrome had been progressing for 2 years.", + "MRI of medulla objectified an extramedullary lesion at L3-L4.", + "The lesion was diagnosed as neurinoma.", + "A complete resection of the tumor was performed.", + "A section of the filum terminale was resected.", + "Histology confirmed the diagnosis of paraganglioma.", + "The clinical course was characterized by a complete recovery of the deficit." + ] + }, + { + "id": "multiclinsum_test_2891_en.txt", + "fulltext": "A 74-year-old female patient presented with an abnormal shadow on chest computed tomography (CT) at a medical checkup and subsequently visited our hospital. Chest CT showed a 17 mm × 8 mm ground-glass opacity with approximately 30% solid component in the right superior segment (S6) . The patient had undergone radical treatment of right breast cancer staged at pT2N0M0 IIA, followed by four cycles of postoperative adjuvant chemotherapy 11 years prior. All other medical history was unremarkable.\nRelevant examinations were performed after admission, and no obvious contraindications to surgery were observed. Because it was difficult to palpable the lesion and the location of lesion was closed to the bronchus, a thoracoscopic right S6 segmentectomy was planned. We performed thoracoscopic surgery using two ports. We made a 2-cm incision in the 7th intercostal space of the right midaxillary line and a 4-cm incision in the 4th intercostal space of the right anterior axillary line as the observation and operating holes, respectively. Pleural adhesions were observed throughout the thoracic cavity perioperatively. The right lung was found to be divided into three lobes after being released. The horizontal and posterior oblique fissures were poorly developed, and the intersegmental plane could not be distinguished. Digital palpation indicated that the nodule was located in a high position, and lifting the right upper lobe revealed the suspected location of the nodule in the upper lobe. The interlobar fissures were separated, and the posterior segmental and superior segmental arteries were located following the pulmonary trunk arteries . After labelling the nodule on the pleural surface, multiple comparisons were performed, and the nodule was eventually found in the S2 of the right upper lobe . So the recurrent and ascending arteries were dissociated and resected. Then, the posterior segmental bronchus (B2) was exposed and transected. Finally, the right lung was reventilated with pure oxygen and the intersegmental plane was clear after 20 min. The intersegmental plane was divided along the inflation-deflation line using the endostaplers; thus, resection of the S2 of the right upper lobe was completed . The tumor was 3 cm away from the incisal margin. As intraoperative pathology analysis revealed minimally invasive adenocarcinoma (MIA), hilar lymph node sampling was performed. On postoperative day 2, the right lung was completely redilated on CT , and postoperative pathological examination revealed MIA with negative surrounding lymph nodes.\nWe reviewed lung CT images and performed three-dimensional (3D) reconstructions using Mimics Medical 21.0 software postoperatively. It revealed that the B2 originated from the bronchus intermedius, the posterior segmental artery (A2) of the right upper lung lobe bifurcated into the A2a and A2b branching from the recurrent and ascending arteries, respectively, and the right superior pulmonary vein had no central vein but a posterior intrasegmental vein ( V2t ) that travelled below the S2 .", + "fulltext_subclaims": [ + "The patient is a 74-year-old female.", + "The patient presented with an abnormal shadow on chest computed tomography (CT) at a medical checkup.", + "Chest CT showed a 17 mm × 8 mm ground-glass opacity with approximately 30% solid component in the right superior segment (S6).", + "The patient had undergone radical treatment of right breast cancer staged at pT2N0M0 IIA.", + "The patient had four cycles of postoperative adjuvant chemotherapy 11 years prior.", + "A thoracoscopic right S6 segmentectomy was planned.", + "We performed thoracoscopic surgery using two ports.", + "We made a 2-cm incision in the 7th intercostal space of the right midaxillary line as the observation hole.", + "We made a 4-cm incision in the 4th intercostal space of the right anterior axillary line as the operating hole.", + "Pleural adhesions were observed throughout the thoracic cavity perioperatively.", + "The horizontal and posterior oblique fissures were poorly developed.", + "The intersegmental plane could not be distinguished.", + "Digital palpation indicated that the nodule was located in a high position.", + "The interlobar fissures were separated.", + "The posterior segmental and superior segmental arteries were located following the pulmonary trunk arteries.", + "The nodule was eventually found in the S2 of the right upper lobe.", + "The recurrent and ascending arteries were dissociated and resected.", + "The posterior segmental bronchus (B2) was exposed and transected.", + "The intersegmental plane was divided along the inflation-deflation line using the endostaplers.", + "Resection of the S2 of the right upper lobe was completed.", + "The tumor was 3 cm away from the incisal margin.", + "Intraoperative pathology analysis revealed minimally invasive adenocarcinoma (MIA).", + "Hilar lymph node sampling was performed.", + "On postoperative day 2, the right lung was completely redilated on CT.", + "Postoperative pathological examination revealed MIA with negative surrounding lymph nodes.", + "We reviewed lung CT images and performed three-dimensional (3D) reconstructions using Mimics Medical 21.0 software postoperatively.", + "The B2 originated from the bronchus intermedius.", + "The posterior segmental artery (A2) of the right upper lung lobe bifurcated into the A2a and A2b branching from the recurrent and ascending arteries, respectively.", + "The right superior pulmonary vein had no central vein but a posterior intrasegmental vein (V2t) that travelled below the S2." + ], + "summary": "We report a case of thoracoscopic resection of the posterior segment of the right upper lobe of the lung. Preoperatively, the nodule was believed to be located in the superior segment of the right lower lobe. However, intraoperative exploration revealed that the nodule was located in the posterior segment of the right upper lobe, further showing that the bronchi of the posterior segment of the right lung opened into the bronchus intermedius. The procedure was completed uneventfully. Postoperative retrospective three-dimensional (3D) reconstruction of the lung CT images confirmed that the bronchi of the posterior segment of the right upper lobe originated from the bronchus intermedius.", + "summary_subclaims": [ + "We report a case of thoracoscopic resection of the posterior segment of the right upper lobe of the lung.", + "Preoperatively, the nodule was believed to be located in the superior segment of the right lower lobe.", + "Intraoperative exploration revealed that the nodule was located in the posterior segment of the right upper lobe.", + "The bronchi of the posterior segment of the right lung opened into the bronchus intermedius.", + "The procedure was completed uneventfully.", + "Postoperative retrospective three-dimensional (3D) reconstruction of the lung CT images confirmed that the bronchi of the posterior segment of the right upper lobe originated from the bronchus intermedius." + ] + }, + { + "id": "multiclinsum_test_1943_en.txt", + "fulltext": "A 16-year-old boy was admitted to the local health center for evaluation of dyspnea, cough, chest pain and a body temperature of 39°C. He was normotensive with a heart rate of 115 beats per minute and a respiratory rate of 25 breaths per minute. The complete blood count revealed elevated white blood cells (15.130/μl) and an erythrocyte sedimentation rate of 105 mm. Serum electrolytes, hepatic and renal function tests were normal.\nHe reported that the symptoms had occurred after attending a party for teenagers, during which he had consumed a large quantity of alcohol and had an episode of vomiting. He also reported that he had practiced a fire-eating performance during the party using liquid paraffin, without knowledge of inhaling any of it. A chest radiograph showed infiltration in the right middle lobe which was diagnosed as aspiration pneumonia, and he was treated at the local health center with a combination of antibiotics (a macrolide and a second-generation cephalosporin). After 5 days of treatment, because of clinical deterioration, he was referred to a pulmonary clinic.\nSpirometry revealed severe restriction of lung function (a forced vital capacity 68% of the normal value). Arterial blood gas measurements were within normal ranges: pH = 7.38, pCO2 = 36.3 mmHg, pO2 = 98.5 mmHg and sO2 = 97.4%. A chest computed tomography scan was performed, which showed consolidation with an air bronchogram in the right middle lobe, and areas of atelectasis and ground glass opacities in the middle and lower right lobes .\nBronchoscopy presented inflamed, hyperemic mucosa, especially on the right side. Bronchoalveolar lavage fluid was hemorrhagic and revealed cytoplasmic vacuolation of the macrophages, lipid-laden alveolar macrophages detected by lipid staining and oil-red-O stain, and neutrophilia (23%; Figure ). Owing to the bronchoalveolar lavage fluid findings and the history of fire-eating, the patient was diagnosed with hydrocarbon pneumonitis and was treated with systemic steroids (intravenous prednisolone 25 mg × 2) and intravenous antibiotics. Steroids were prescribed for 21 days: 6 days during the patient's hospitalization followed by tapering doses over the next 15 days. There was significant clinical and radiologic resolution 6 days after treatment was initiated .", + "fulltext_subclaims": [ + "The patient was a 16-year-old boy.", + "He was admitted to the local health center for evaluation of dyspnea, cough, chest pain and a body temperature of 39°C.", + "He was normotensive.", + "His heart rate was 115 beats per minute.", + "His respiratory rate was 25 breaths per minute.", + "The complete blood count revealed elevated white blood cells (15.130/μl).", + "The erythrocyte sedimentation rate was 105 mm.", + "Serum electrolytes, hepatic and renal function tests were normal.", + "He reported that the symptoms had occurred after attending a party for teenagers.", + "He had consumed a large quantity of alcohol.", + "He had an episode of vomiting.", + "He had practiced a fire-eating performance during the party using liquid paraffin.", + "A chest radiograph showed infiltration in the right middle lobe.", + "The infiltration was diagnosed as aspiration pneumonia.", + "He was treated at the local health center with a combination of antibiotics (a macrolide and a second-generation cephalosporin).", + "After 5 days of treatment, he was referred to a pulmonary clinic.", + "Spirometry revealed severe restriction of lung function.", + "The forced vital capacity was 68% of the normal value.", + "Arterial blood gas measurements were within normal ranges.", + "A chest computed tomography scan showed consolidation with an air bronchogram in the right middle lobe.", + "There were areas of atelectasis and ground glass opacities in the middle and lower right lobes.", + "Bronchoscopy presented inflamed, hyperemic mucosa, especially on the right side.", + "Bronchoalveolar lavage fluid was hemorrhagic.", + "The bronchoalveolar lavage fluid revealed cytoplasmic vacuolation of the macrophages.", + "Lipid-laden alveolar macrophages were detected by lipid staining and oil-red-O stain.", + "Neutrophilia was 23%.", + "The patient was diagnosed with hydrocarbon pneumonitis.", + "He was treated with systemic steroids (intravenous prednisolone 25 mg × 2).", + "He was treated with intravenous antibiotics.", + "Steroids were prescribed for 21 days.", + "There was significant clinical and radiologic resolution 6 days after treatment was initiated." + ], + "summary": "Six hours after participating in a party for teenagers, a 16-year-old boy developed dyspnea, cough, a fever (39 degrees C) and chest pain. A chest radiograph showed infiltration in the right middle lobe. The patient reported alcohol abuse during the party and an episode of vomiting a few hours thereafter. He also reported practicing a fire-eating performance at the party using liquid paraffin, but was unaware of inhaling any of it. The radiographic infiltration was diagnosed as an aspiration pneumonia and he was treated at the local health center with antibiotics. Five days later, because of clinical deterioration, he was referred to a pulmonary clinic. A chest computed tomography scan was performed which showed consolidation with an air bronchogram in the right middle lobe and areas of atelectasis and ground glass opacities in the middle and lower right lobes. Spirometry revealed severe restriction of lung function. A bronchoscopy revealed inflamed, hyperemic mucosa. Bronchoalveolar lavage fluid revealed lipid-laden alveolar macrophages, which were detected by lipid staining, and neutrophilia. The patient was finally diagnosed with hydrocarbon pneumonitis and he was treated with systemic steroids and antibiotics. After 6 days of treatment there was complete clinical and significant radiologic regression.", + "summary_subclaims": [ + "Six hours after participating in a party for teenagers, a 16-year-old boy developed dyspnea, cough, a fever (39 degrees C) and chest pain.", + "A chest radiograph showed infiltration in the right middle lobe.", + "The patient reported alcohol abuse during the party and an episode of vomiting a few hours thereafter.", + "He also reported practicing a fire-eating performance at the party using liquid paraffin, but was unaware of inhaling any of it.", + "The radiographic infiltration was diagnosed as an aspiration pneumonia.", + "He was treated at the local health center with antibiotics.", + "Five days later, because of clinical deterioration, he was referred to a pulmonary clinic.", + "A chest computed tomography scan was performed which showed consolidation with an air bronchogram in the right middle lobe and areas of atelectasis and ground glass opacities in the middle and lower right lobes.", + "Spirometry revealed severe restriction of lung function.", + "A bronchoscopy revealed inflamed, hyperemic mucosa.", + "Bronchoalveolar lavage fluid revealed lipid-laden alveolar macrophages, which were detected by lipid staining, and neutrophilia.", + "The patient was finally diagnosed with hydrocarbon pneumonitis.", + "He was treated with systemic steroids and antibiotics.", + "After 6 days of treatment there was complete clinical and significant radiologic regression." + ] + }, + { + "id": "multiclinsum_test_771_en.txt", + "fulltext": "A 53-year old man presented to his local district general hospital with epigastric pain. Relevant past medical history includes type 2 diabetes mellitus, and a history of excessive alcohol consumption of 44 units/week.\nThe patient underwent an abdominal dual-phase contrasted computed tomography (CT) scan. In addition to background liver steatosis and right liver atrophy, a central mass was identified at the bifurcation of the right anterior and posterior portal vein. The lesion was enhanced during the arterial phase, and mild contrast washout at the portal venous phase, suggestive of possible hepatocellular carcinoma (HCC) . The mass had increased in size as compared to previous imaging. Subsequent magnetic resonance imaging (MRI) liver confirmed the same mass in the right lobe with peripheral biliary ductal dilatation. This then raised the possibility of a clinical diagnosis of intrahepatic cholangiocarcinoma .\nPreoperative bilirubin was 15 μmol/L (normal range: 4–22 μmol/L), alkaline phosphatase was 110U/L (42–98U/L) and aspartate transaminase was 39 IU/L (6–34 IU/L). Alpha-Feto Protein (AFP) and carbohydrate antigen 19–9 (CA19-9) were 3.7kU/ml (<4kU/ml) and 7 (<33kU/L) respectively.\nThis patient was then referred to our tertiary hepato-pancreato-biliary centre for further management. Having discussed this case in our multi-disciplinary meeting, fluorodeoxyglucose—positron emission tomography (FDG-PET) CT scan was performed and excluded extrahepatic metastasis. No FDG uptake was demonstrated within the lesion as compared to the background liver parenchyma.\nThe patient was listed for surgical resection with curative intent. Right lobe hepatectomy and excision of the extrahepatic biliary tree with the reconstruction of a hepaticojejunostomy was performed. There were no postoperative complications. Patient made a good post-operative recovery and was subsequently discharged home. 68Ga-DOTA-conjugated peptide PET scan completed 4 weeks post-operation did not demonstrate any evidence of residual disease.\nA 20 mm diameter friable, greyish and pale tumor occupied the lumen of the right hepatic duct and infiltrated into the surrounding liver and hilar adipose tissue. The background liver appeared yellowish with vague accentuation of the lobular architecture.\nAt light macroscopy , approximately half of the tumour mass formed an intraductal growth, with the rest of the tumour infiltrating into periductal fibrovascular tissue and local liver parenchyma. Both the intraductal and periductal infiltrative aspects were composed of large sheets of relatively monomorphic cells mixed with a rhabdoid or plasmacytoid appearance. Nuclei were generally round and regular and often showed a “salt-and-pepper” appearance with focally increased and dense chromatin. Immunohistochemistry in this cell population stained strongly and diffusely for synaptophysin (DAKO, M0776, 1:100) and chromogranin (DAKO, 1:100) . The proliferative rate estimated with immunohistochemical analysis for Ki67 (MIB-1, DAKO, M0701, 1:100) was up to 8 % and up to three mitotic figures were present in 50 HPF .\nA minor component of the cell population (estimated to be around 30 %) showed a signet ring appearance with clarification of the cytoplasm suggestive of intracellular mucin , which stained weakly with alcian-blue-dPAS and showed focal acinar formation with intraluminal mucin secretion . With the limitation of single epitope immunohistochemistry on serial sections this cell population appeared to retain the expression of chromogranin and synaptophysin. This also showed cytoplasmic or membranous expression of MUC-1, (Abcam, Ab696-250, 1:100) predominantly in the deeper aspect of the tumour, but did not stain for MUC-2 (Novocastra, NCL MUC2, 1:100), MUC5 (Novocastra, NCL MUC5, 1:100) or MUC-6 (Novocastra, NCL MUC6, 1:100). There was weak and diffuse nuclear staining for CDX2 (Leica Bond RTU, PA0535) throughout the tumour. Staining for CA19.9 (Leica RTU, PA 0424) highlighted the superficial component of the intraductal growing tumor, in keeping with residual biliary epithelium . The background biliary epithelium did not reveal dysplasia or metaplastic changes. Hep-Par1 staining of tumour was negative .\nThe background liver showed steatohepatitis, mainly macrovesicular, affecting around 30 % of the hepatocytes associated with a mild bridging fibrosis.", + "fulltext_subclaims": [ + "The patient is a 53-year-old man.", + "The patient presented with epigastric pain.", + "The patient has a history of type 2 diabetes mellitus.", + "The patient has a history of excessive alcohol consumption of 44 units/week.", + "The patient underwent an abdominal dual-phase contrasted computed tomography (CT) scan.", + "The CT scan identified a central mass at the bifurcation of the right anterior and posterior portal vein.", + "The lesion was enhanced during the arterial phase.", + "The lesion showed mild contrast washout at the portal venous phase.", + "The mass had increased in size as compared to previous imaging.", + "Subsequent magnetic resonance imaging (MRI) liver confirmed the same mass in the right lobe.", + "The MRI showed peripheral biliary ductal dilatation.", + "Preoperative bilirubin was 15 μmol/L.", + "Preoperative alkaline phosphatase was 110 U/L.", + "Preoperative aspartate transaminase was 39 IU/L.", + "Alpha-Feto Protein (AFP) was 3.7 kU/ml.", + "Carbohydrate antigen 19–9 (CA19-9) was 7 kU/L.", + "The patient was referred to a tertiary hepato-pancreato-biliary centre.", + "A fluorodeoxyglucose—positron emission tomography (FDG-PET) CT scan was performed.", + "The FDG-PET CT scan excluded extrahepatic metastasis.", + "No FDG uptake was demonstrated within the lesion.", + "The patient was listed for surgical resection with curative intent.", + "Right lobe hepatectomy and excision of the extrahepatic biliary tree with reconstruction of a hepaticojejunostomy were performed.", + "There were no postoperative complications.", + "A 20 mm diameter friable, greyish and pale tumor occupied the lumen of the right hepatic duct.", + "The tumor infiltrated into the surrounding liver and hilar adipose tissue.", + "At light macroscopy, approximately half of the tumour mass formed an intraductal growth.", + "The rest of the tumour infiltrated into periductal fibrovascular tissue and local liver parenchyma.", + "Both the intraductal and periductal infiltrative aspects were composed of large sheets of relatively monomorphic cells mixed with a rhabdoid or plasmacytoid appearance.", + "Nuclei were generally round and regular and often showed a “salt-and-pepper” appearance.", + "Immunohistochemistry stained strongly and diffusely for synaptophysin.", + "Immunohistochemistry stained strongly and diffusely for chromogranin.", + "The proliferative rate estimated with Ki67 was up to 8%.", + "Up to three mitotic figures were present in 50 HPF.", + "A minor component of the cell population showed a signet ring appearance with clarification of the cytoplasm.", + "This component stained weakly with alcian-blue-dPAS.", + "This component showed focal acinar formation with intraluminal mucin secretion.", + "This cell population retained the expression of chromogranin and synaptophysin.", + "This cell population showed cytoplasmic or membranous expression of MUC-1.", + "This cell population did not stain for MUC-2, MUC5, or MUC-6.", + "There was weak and diffuse nuclear staining for CDX2 throughout the tumour.", + "Staining for CA19.9 highlighted the superficial component of the intraductal growing tumor.", + "The background biliary epithelium did not reveal dysplasia or metaplastic changes.", + "Hep-Par1 staining of tumour was negative.", + "The background liver showed steatohepatitis, mainly macrovesicular, affecting around 30% of the hepatocytes.", + "The background liver showed mild bridging fibrosis." + ], + "summary": "A 53-year old man presented with epigastric pain on a background of excessive alcohol consumption. Contrast-enhanced computed tomography imaging of the liver revealed a central enhancing mass located at the bifurcation of right anterior and posterior portal veins. Magnetic resonance imaging demonstrated intrahepatic biliary duct dilatation distal to the mass. The patient underwent a right lobe hepatectomy and excision of the extrahepatic biliary tree with formation of a hepaticojejunostomy. Histopathological finding of the specimen revealed an intraductal tumour with predominant neuroendocrine immunohistochemical phenotype and infiltration into nearby tissue. An element of glandular differentiation on immunohistochemistry confirmed the lesion as MANEC.", + "summary_subclaims": [ + "A 53-year old man presented with epigastric pain on a background of excessive alcohol consumption.", + "Contrast-enhanced computed tomography imaging of the liver revealed a central enhancing mass located at the bifurcation of right anterior and posterior portal veins.", + "Magnetic resonance imaging demonstrated intrahepatic biliary duct dilatation distal to the mass.", + "The patient underwent a right lobe hepatectomy.", + "The patient underwent excision of the extrahepatic biliary tree.", + "The patient underwent formation of a hepaticojejunostomy.", + "Histopathological finding of the specimen revealed an intraductal tumour with predominant neuroendocrine immunohistochemical phenotype.", + "Histopathological finding of the specimen revealed infiltration into nearby tissue.", + "An element of glandular differentiation on immunohistochemistry confirmed the lesion as MANEC." + ] + }, + { + "id": "multiclinsum_test_3165_en.txt", + "fulltext": "A female infant, 2 months of age, previously healthy, was admitted to the pediatric emergency department. The mother reported weight loss, colic, alternating hunger cries with lethargy, mild diarrhea and worsening vomiting, with onset 5 days ago. She also reported previous symptoms of nasal congestion, sporadic cough, conjunctivitis, small skin vesicles on the chest and absence of fever. The nasopharyngeal reverse transcription-polymerase chain reaction (RT-PCR) test result for SARS-CoV-2 was positive. The mother had become infected with SARS-CoV-2 10 days before the infant. On physical examination, the infant was very irritable, alternating with lethargy, with a face of abdominal colic pain associated with multiple feeding interruptions, moderate dehydration and hypothermia (<36°C). The weight was 4.8kg; the skin had a lattice appearance, with prolonged capillary filling and decreased urine flow. The pulse was 125 beats/minute, respiratory rate 54 breaths/minute, and pulse oximetry oxygen saturation was 97% in room air. The patient was transferred to the pediatric intensive care unit (PICU) after volume resuscitation.\n\nThe patient was a full term newborn with no pre-existing illness or antibiotic use, who was fed breast milk and infant formula supplement from the second week of life.\n\nData from biochemistry, urine, faeces, coagulation function tests and infection biomarkers, performed after confirmation of SARS-CoV-2 infection at admission and follow-up. Serology for SARS-CoV-2 was positive for IgM (2.11AU/mL, with normal range <0.90) and negative for IgG. PCR for SARS-CoV-2 PCR remained positive in faeces for more than 27 days, despite the respiratory tract examination already being negative. Additional viral panel tests, urine and faeces culture were negative, and only the nucleic acid amplification test (NAAT or PCR) was positive for C. difficile .\n\nMultislice helical computed tomography (CT) of the chest, echocardiography and abdominal ultrasound were normal.\n\nDuring 4 days of admission to the NICU, the patient persisted with abdominal cramps and required additional amounts of intravenous fluids due to poor acceptance of breast milk and infant formula. The proton pump inhibitor initially prescribed was discontinued. No antiviral, glucocorticoid or antimicrobial was prescribed to the patient.\n", + "fulltext_subclaims": [ + "The patient is a 2-month-old female infant.", + "The mother reported weight loss.", + "The mother reported colic.", + "The mother reported alternating hunger cries with lethargy.", + "The mother reported mild diarrhea.", + "The mother reported worsening vomiting.", + "The mother reported previous symptoms of nasal congestion.", + "The mother reported sporadic cough.", + "The mother reported conjunctivitis.", + "The mother reported small skin vesicles on the chest.", + "The nasopharyngeal RT-PCR test for SARS-CoV-2 was positive.", + "The mother had become infected with SARS-CoV-2 10 days before the infant.", + "On physical examination, the infant was very irritable.", + "On physical examination, the infant had a face of abdominal colic pain.", + "The infant had multiple feeding interruptions.", + "The infant had moderate dehydration.", + "The infant had hypothermia (<36°C).", + "The weight was 4.8kg.", + "The skin had a lattice appearance.", + "Capillary filling was prolonged.", + "Urine flow was decreased.", + "The pulse was 125 beats/minute.", + "The respiratory rate was 54 breaths/minute.", + "Oxygen saturation was 97% in room air.", + "The patient was transferred to the PICU after volume resuscitation.", + "The patient was a full term newborn.", + "The patient had no pre-existing illness.", + "The patient was fed breast milk and infant formula supplement from the second week of life.", + "Serology for SARS-CoV-2 was positive for IgM.", + "Serology for SARS-CoV-2 was negative for IgG.", + "PCR for SARS-CoV-2 remained positive in faeces for more than 27 days.", + "The nucleic acid amplification test was positive for C. difficile.", + "Multislice helical CT of the chest was normal.", + "Echocardiography was normal.", + "Abdominal ultrasound was normal.", + "The patient persisted with abdominal cramps during 4 days of admission.", + "The patient required additional intravenous fluids.", + "The proton pump inhibitor was discontinued.", + "No antiviral was prescribed.", + "No glucocorticoid was prescribed.", + "No antimicrobial was prescribed." + ], + "summary": "We report a case of a newborn with severe acute respiratory syndrome coronavirus 2 (SARS-CoV-2) infection with predominantly vomiting. The patient also presented with colic, difficulty in breast feeding, loose stools and mild rhinorrhea, without fever. There was evidence of coagulation disorders, increased interleukin 10 and moderate dehydration, which justified admission to the intensive care unit. Simultaneously, the patient was diagnosed with Clostridioides difficile infection, which may have facilitated the persistence of SARS-CoV-2 in the faeces for more than 27 days, even after a negative nasopharyngeal test. This co-infection may have exacerbated the gastrointestinal signs and symptoms and increased the possibility of transmission of SARS-CoV-2 and Clostridioides . The patient was kept on breast feeding and formula milk, received intravenous hydration and was discharged from hospital without complications after 4 days of admission.\n", + "summary_subclaims": [ + "The patient was a newborn with SARS-CoV-2 infection.", + "The patient had predominantly vomiting.", + "The patient also presented with colic.", + "The patient had difficulty in breast feeding.", + "The patient had loose stools.", + "The patient had mild rhinorrhea.", + "The patient did not have fever.", + "There was evidence of coagulation disorders.", + "There was increased interleukin 10.", + "There was moderate dehydration.", + "Admission to the intensive care unit was justified.", + "The patient was diagnosed with Clostridioides difficile infection.", + "Clostridioides difficile infection may have facilitated the persistence of SARS-CoV-2 in the faeces for more than 27 days.", + "SARS-CoV-2 was negative in the nasopharyngeal test.", + "The co-infection may have exacerbated the gastrointestinal signs and symptoms.", + "The co-infection may have increased the possibility of transmission of SARS-CoV-2 and Clostridioides.", + "The patient was kept on breast feeding.", + "The patient received intravenous hydration.", + "The patient was discharged from hospital after 4 days of admission.", + "The patient was discharged without complications." + ] + }, + { + "id": "multiclinsum_test_3373_en.txt", + "fulltext": "A 21-year-old man visited a clinic with a chief complaint of right inguinal pain. Abdominal ultrasonography revealed a huge intra-abdominal mass, and he was referred to our hospital for further examination. He had no specific family history but had a history of autism spectrum disorder and bronchial asthma, with no history of trauma or abdominal surgery. The abdomen was mildly distended and soft, and the tumor was not palpable. Laboratory examinations showed no abnormalities in blood count, biochemistry, or coagulation markers, no elevation of tumor markers, and no elevation of immunoglobulins. Abdominopelvic computed tomography (CT) showed a huge mass with a maximum diameter of 34 cm and well-defined borders, extending from the upper abdomen to the pelvis. Magnetic resonance imaging (MRI) revealed an intra-abdominal tumor 34 × 15 × 8 cm with partial signal hyperintensity on T2-weighted imaging, hypointensity on T1-weighted imaging. No internal calcification, fatty, or blood components were evident, and a portion of the tumor appeared to be in contact with the gastric body. Due to the history of bronchial asthma, a contrast-enhanced examination could not be performed. Endoscopic ultrasonography showed a heterogeneous hypoechoic internal cavity, but endoscopic ultrasound-guided fine-needle aspiration (EUS-FNA) was not performed, given the risk of seeding. Although no definitive diagnosis or organ of origin was confirmed preoperatively for the tumor, we performed surgery under suspicion of gastrointestinal stromal tumor, desmoid tumor, or mesenteric tumor.\n\nThe patient was placed in the supine position, and laparotomy was performed through upper and lower median incisions and a left transverse incision. Intraoperative findings showed a giant tumor covered with a capsule occupying most of the left side of the abdominal cavity, extending from the pelvis to the diaphragm. The tumor showed firm adhesions to the stomach, transverse colon, and diaphragm without invasion of other organs. The omentum, with dilated vessels, was also adherent to the tumor, so the tumor had to be partially resected en bloc with portions of the stomach, transverse colon, and diaphragm. After tumor resection, primary anastomosis of the colon and closure of the diaphragm were performed. The tumor appeared to have been completely excised without rupture of the capsule. The operative time was 3 h 57 min, with a total blood loss of 110 mL. The excised specimen measured 38 × 21 × 8 cm and weighed 6400 g. The surface was smooth, and the interior was homogeneously filled with tumor on macroscopic examination. Pathological examination revealed atypical cells with spindle-shaped nuclei and collagen fiber hyperplasia in the stroma. Immunostaining showed negative results for c-kit, CD34, desmin, and S-100, while positive results for β-catenin confirmed the diagnosis of a desmoid tumor. Pathological results for the surgical margins were negative, confirming complete surgical resection. Despite pathological examination of the resected organs, determining the primary site of tumor origin was difficult. The patient was discharged 17 days after surgery, despite the appearance of surgical site infection. Colonoscopy revealed no polyps. A CT scan conducted 12 months after surgery showed a nodule 3.0 cm in diameter near the suture line of the gastric body; however, its size remained unchanged on a subsequent CT scan taken 9 months later, 21 months postoperatively. The patient is under close follow-up.", + "fulltext_subclaims": [ + "The patient was a 21-year-old man.", + "He visited a clinic with a chief complaint of right inguinal pain.", + "Abdominal ultrasonography revealed a huge intra-abdominal mass.", + "He was referred to the hospital for further examination.", + "He had a history of autism spectrum disorder.", + "He had a history of bronchial asthma.", + "The abdomen was mildly distended and soft.", + "The tumor was not palpable.", + "Laboratory examinations showed no abnormalities in blood count.", + "Laboratory examinations showed no elevation of tumor markers.", + "Abdominopelvic CT showed a huge mass with a maximum diameter of 34 cm.", + "MRI revealed an intra-abdominal tumor 34 × 15 × 8 cm.", + "The tumor appeared to be in contact with the gastric body.", + "A contrast-enhanced examination could not be performed due to the history of bronchial asthma.", + "Endoscopic ultrasonography showed a heterogeneous hypoechoic internal cavity.", + "EUS-FNA was not performed, given the risk of seeding.", + "No definitive diagnosis or organ of origin was confirmed preoperatively.", + "Surgery was performed under suspicion of gastrointestinal stromal tumor.", + "Surgery was performed under suspicion of desmoid tumor.", + "Surgery was performed under suspicion of mesenteric tumor.", + "Laparotomy was performed through upper and lower median incisions.", + "Intraoperative findings showed a giant tumor covered with a capsule.", + "The tumor extended from the pelvis to the diaphragm.", + "The tumor showed firm adhesions to the stomach.", + "The tumor showed firm adhesions to the transverse colon.", + "The tumor showed firm adhesions to the diaphragm.", + "The omentum was adherent to the tumor.", + "The tumor was partially resected en bloc with portions of the stomach.", + "The tumor was partially resected en bloc with portions of the transverse colon.", + "The tumor was partially resected en bloc with portions of the diaphragm.", + "Primary anastomosis of the colon was performed.", + "The diaphragm was closed after tumor resection.", + "The tumor appeared to have been completely excised without rupture of the capsule.", + "The excised specimen measured 38 × 21 × 8 cm.", + "The excised specimen weighed 6400 g.", + "Pathological examination revealed atypical cells with spindle-shaped nuclei.", + "Immunostaining showed negative results for c-kit.", + "Immunostaining showed negative results for CD34.", + "Immunostaining showed negative results for desmin.", + "Immunostaining showed negative results for S-100.", + "Immunostaining showed positive results for β-catenin.", + "The diagnosis was confirmed as a desmoid tumor.", + "Pathological results for the surgical margins were negative.", + "Determining the primary site of tumor origin was difficult.", + "The patient was discharged 17 days after surgery.", + "A CT scan conducted 12 months after surgery showed a nodule 3.0 cm in diameter near the suture line of the gastric body.", + "The nodule's size remained unchanged on a subsequent CT scan taken 9 months later." + ], + "summary": "A 21-year-old man was referred to our hospital for treatment after presenting to a nearby hospital with right inguinal pain. Abdominal magnetic resonance imaging showed an intra-abdominal mass measuring 34 × 15 × 8 cm with partial signal hyperintensity on T2-weighted imaging and hypointensity on T1-weighted imaging, extending from the left abdominal cavity to the pelvic region. Although no definitive diagnosis was obtained preoperatively, surgery was performed under suspicion of gastrointestinal stromal tumor or other significant disease. A mass was identified firmly adherent to the transverse colon, gastric wall, and diaphragm, and these organs were partially resected. The excised specimen measured 38 × 21 × 8 cm and weighed 6400 g. Macroscopically, the tumor showed a smooth surface and homogeneous interior. Pathological examination revealed atypical cells with spindle-shaped nuclei and collagen fiber hyperplasia in the stroma, and immunostaining was negative for c-kit, CD34, desmin, S-100, and positive for β-catenin, leading to a confirmed diagnosis of desmoid tumor. Fifteen months after surgery, a local recurrence with a diameter of 3.0 cm was identified, and the patient remains under careful follow-up.", + "summary_subclaims": [ + "The patient was a 21-year-old man.", + "He was referred to the hospital for treatment.", + "He had right inguinal pain.", + "Abdominal magnetic resonance imaging showed an intra-abdominal mass.", + "The mass measured 34 × 15 × 8 cm.", + "The mass showed partial signal hyperintensity on T2-weighted imaging.", + "The mass showed hypointensity on T1-weighted imaging.", + "The mass extended from the left abdominal cavity to the pelvic region.", + "No definitive diagnosis was obtained preoperatively.", + "Surgery was performed under suspicion of gastrointestinal stromal tumor or other significant disease.", + "A mass was identified firmly adherent to the transverse colon.", + "The mass was identified firmly adherent to the gastric wall.", + "The mass was identified firmly adherent to the diaphragm.", + "The transverse colon, gastric wall, and diaphragm were partially resected.", + "The excised specimen measured 38 × 21 × 8 cm.", + "The excised specimen weighed 6400 g.", + "Macroscopically, the tumor showed a smooth surface.", + "Macroscopically, the tumor showed a homogeneous interior.", + "Pathological examination revealed atypical cells with spindle-shaped nuclei.", + "Pathological examination revealed collagen fiber hyperplasia in the stroma.", + "Immunostaining was negative for c-kit.", + "Immunostaining was negative for CD34.", + "Immunostaining was negative for desmin.", + "Immunostaining was negative for S-100.", + "Immunostaining was positive for β-catenin.", + "The diagnosis was confirmed as desmoid tumor.", + "Fifteen months after surgery, a local recurrence with a diameter of 3.0 cm was identified.", + "The patient remains under careful follow-up." + ] + }, + { + "id": "multiclinsum_test_933_en.txt", + "fulltext": "A 23-year-old female presented to the emergency department with a 1-day history of fits. It was described as a generalized tonic-clonic seizure with loss of consciousness for about 30 minutes. There was no aura or focal neurological deficit. She reported having headache, vertigo, disturbed sleep, and reduced appetite. The patient had a history of similar seizures that progressively worsened over the last 1 month. The patient was taking sodium valproate for the last 6 months but the seizures were uncontrolled despite of strict medication compliance. In addition, she also had generalized body weakness, intermittent twitching and tightness in the hands for the past 7 years. She did not have a history of seizures, head trauma, central nervous system infection, stroke, hypertension, diabetes, thyroid disease, or autoimmune disease. Family history was not significant for seizures disorder.\nHer vital signs were as follows: blood pressure was 120/70 mm Hg; pulse rate was 74 beats per minute, respiratory rate of 20 breaths per minute, and body temperature of 37.3°C. Neurological examination revealed clear consciousness with no cognitive impairment or cranial nerve dysfunction. Her systemic and general physical examinations were unremarkable except for a positive Chvostek sign.\nInitially workup was done for the metabolic causes of seizures and the laboratory evaluation revealed hypocalcemia as shown in\nComputed tomographic (CT) scan of the brain was ordered that diffuse brain parenchymal calcification involving globus pallidus, putamen, caudate, internal capsule, thalamus, dentate nucleus, and subcortical white matter in scattered areas of fronto parietal regions as shown in .\nBased on the patient laboratory investigation and radiological finding a differential diagnosis of fahr’s disease and fahr’s syndrome were made. Initially the patient received injection calcium gluconate 20 mL of calcium gluconate 10% diluted in 50 mL of dextrose infused over 10 minutes by intravenous route, injection midazolam and an injection diavalproex sodium 500 mg. Patient was admitted to the medical unit and further workup for hypocalcemia was initiated that revealed hypoparathyroidism as shown in the .\nDue to the absence of secondary causes that is, congenital defects, thyroid surgery, neck radiation in the patient history, negative anti-nuclear antibodies a diagnosis of Fahr’s syndrome secondary to primary hypoparathyroidism was made. The patient was placed on oral sodium valproate 500 mg twice daily, calcium citrate 600 mg twice daily, vitamin D3 50 000 once weekly for 6 weeks. At sixth week follow up, the patient remained symptomatic having 2 episodes of seizure in the last 15 days despite of strict compliance to anti-seizures and calcium supplements. Her calcium remained low (5.2 mg/dL). She was prescribed oral prednisolone 2 mg/kg for 4 weeks along with the anti-seizures and calcium and vitamin D supplement. After 1 month of starting the steroid therapy her calcium level raised to 7.2 mg/dL, she remained asymptomatic and her steroid therapy was tapered.", + "fulltext_subclaims": [ + "The patient is a 23-year-old female.", + "She presented with a 1-day history of fits.", + "The seizure was described as generalized tonic-clonic with loss of consciousness for about 30 minutes.", + "There was no aura.", + "There was no focal neurological deficit.", + "She reported headache.", + "She reported vertigo.", + "She reported disturbed sleep.", + "She reported reduced appetite.", + "She had a history of similar seizures that progressively worsened over the last 1 month.", + "She was taking sodium valproate for the last 6 months.", + "The seizures were uncontrolled despite strict medication compliance.", + "She had generalized body weakness.", + "She had intermittent twitching and tightness in the hands for the past 7 years.", + "She did not have a history of seizures.", + "She did not have a history of head trauma.", + "She did not have a history of central nervous system infection.", + "She did not have a history of stroke.", + "She did not have a history of hypertension.", + "She did not have a history of diabetes.", + "She did not have a history of thyroid disease.", + "She did not have a history of autoimmune disease.", + "Family history was not significant for seizure disorder.", + "Her blood pressure was 120/70 mm Hg.", + "Her pulse rate was 74 beats per minute.", + "Her respiratory rate was 20 breaths per minute.", + "Her body temperature was 37.3°C.", + "Neurological examination revealed clear consciousness.", + "There was no cognitive impairment.", + "There was no cranial nerve dysfunction.", + "Systemic and general physical examinations were unremarkable except for a positive Chvostek sign.", + "Initial workup was done for metabolic causes of seizures.", + "Laboratory evaluation revealed hypocalcemia.", + "CT scan of the brain showed diffuse brain parenchymal calcification involving globus pallidus, putamen, caudate, internal capsule, thalamus, dentate nucleus, and subcortical white matter in scattered areas of fronto parietal regions.", + "A differential diagnosis of Fahr’s disease and Fahr’s syndrome was made.", + "The patient received injection calcium gluconate 20 mL of calcium gluconate 10% diluted in 50 mL of dextrose infused over 10 minutes by intravenous route.", + "The patient received injection midazolam.", + "The patient received injection diavalproex sodium 500 mg.", + "The patient was admitted to the medical unit.", + "Further workup for hypocalcemia was initiated.", + "Hypoparathyroidism was found.", + "Due to the absence of secondary causes such as congenital defects, thyroid surgery, or neck radiation in the patient history, a diagnosis of Fahr’s syndrome secondary to primary hypoparathyroidism was made.", + "The patient was placed on oral sodium valproate 500 mg twice daily.", + "The patient was placed on calcium citrate 600 mg twice daily.", + "The patient was placed on vitamin D3 50,000 once weekly for 6 weeks.", + "At the sixth week follow-up, the patient remained symptomatic with 2 episodes of seizure in the last 15 days.", + "Her calcium remained low at 5.2 mg/dL.", + "She was prescribed oral prednisolone 2 mg/kg for 4 weeks.", + "After 1 month of starting steroid therapy, her calcium level raised to 7.2 mg/dL.", + "She remained asymptomatic after 1 month of starting steroid therapy.", + "Her steroid therapy was tapered." + ], + "summary": "We presented a case of a 23-year-old female with seizures. Associated symptoms included headache, vertigo, disturbed sleep, and reduced appetite. Her laboratory workup revealed hypocalcemia and low parathyroid hormone level, computed tomographic (CT) scan of the brain showed diffuse calcification in the brain parenchyma. The patient was diagnosed as a case of Fahr's syndrome secondary to hypoparathyroidism. The patient was started on calcium and calcium supplementations along with anti-seizure therapy. Her calcium level raised after the initiation of oral prednisolone and she remained asymptomatic.", + "summary_subclaims": [ + "The patient was a 23-year-old female.", + "The patient had seizures.", + "The patient had headache.", + "The patient had vertigo.", + "The patient had disturbed sleep.", + "The patient had reduced appetite.", + "The laboratory workup revealed hypocalcemia.", + "The laboratory workup revealed a low parathyroid hormone level.", + "The CT scan of the brain showed diffuse calcification in the brain parenchyma.", + "The patient was diagnosed as a case of Fahr's syndrome secondary to hypoparathyroidism.", + "The patient was started on calcium and calcium supplementations.", + "The patient was started on anti-seizure therapy.", + "The patient's calcium level raised after the initiation of oral prednisolone.", + "The patient remained asymptomatic." + ] + }, + { + "id": "multiclinsum_test_3100_en.txt", + "fulltext": "A 20-year-old Caucasian female visited the Emergency Department (ED) with complaints of fever, constant left abdominal pain and generalized profuse fatigue. These symptoms had occurred at rest few days before the ED admission. She also mentioned an episode of dysuria and fever ten days before, which had been treated with ciprofloxacin in the suspect of cystitis. Moreover, she reported having assumed three oral contraceptive pills containing ulipristal acetate in the 30 days before the symptom onset. At the time of presentation, she denied nausea, diarrhea, or constipation, contact with animals, trips abroad, insect, or tick bites.\n\nIn January 2022, the patient had had SARS-CoV2 infection which had required anti-inflammatory therapy with ibuprofen and paracetamol without hospitalization need. She denied previous surgical interventions, autoimmune diseases, or chronic disease for which any chronic therapy was required. She reported no allergy toward drug and environmental allergens. Her relatives had never suffered from liver or biliary disease. In addition, she denied any relationship with hematologic disorders such as hemolytic anemia. Regarding her social habits, she confirmed no excessive assumption of alcohol, and she denied smoking cigarettes. However, she reported a minimal physical activity as well as a high intake of sugar-containing beverages and food.\n\nOn admission, the patient’s initial vitals included blood pressure 100/60 mm Hg, pulse 75 beats per minute, respirations 15 breaths per minute, temperature 37.5°C and an oxygen saturation of 98% on room air. Physical examination revealed an alert, oriented female with grade III obesity (weight 115 kg, height 160 cm). Physical examination revealed severe jaundice involving the muco-cutaneous surfaces and the sclerae. No lymphadenopathies were palpable superficially. Head, ears, eyes, nose, throat (HEENT), neck, cardiovascular, respiratory, musculoskeletal, and neurological examinations were all grossly unremarkable. The abdominal examination revealed mild upper left abdominal pain exacerbated by deep palpation, without tenderness. Murphy and Courvoisier signs were absent. No flapping tremor was elicited.\n\nInitial blood tests indicated leukocytosis with white blood cell (WBC) count 28460/mm3, normochromic normocytic anemia with hemoglobin 7.9 g/dL, platelets count (PLT) 212000/mm3, hyperbilirubinemia with total serum bilirubin 23.11 mg/dL composed prevalently of direct bilirubin 19.36 mg/dL, elevated liver function tests (ALT 244 U/L, AST 202 U/L), cholestasis index (GGT 372 U/L, ALP 300 U/L), and C-reactive protein (CRP) 17 mg/dL. Haptoglobin was depleted and Lactate DeHydrogenase (LDH) was significantly elevated (3190 U/L).\n\nTo better clarify the etiology of these findings, the patient was tested for various infections, including HIV, hepatitis A, E, B, C viruses, cytomegalovirus, syphilis, West Nile virus, Plasmodium malariae, all returning negative results. Furthermore, abdominal ultrasonography and CT scan ruled out biliary obstruction or pancreatic disorders. No evidence of autoimmune hepatitis was found. Interestingly, EBV serology test showed a probable acute infection phase: Virus Capsid Antigen IgM (VCAM) > 160 UI/mL, Early Antigen (D) IgG (EAG) 45.9 UI/mL, Virus Capsid Antigen IgG (VCAG) 47.4 UI/mL and Epstein-Barr Nuclear Antigen (EBNA1) 8.1 UI/mL. The infection acuity was confirmed by EBV DNA titer which was extremely high (123600 copies/mL). Moreover, the direct antiglobulin test for Complement 3 Factor (C3) and cold agglutinin test were positive. Lastly, liver and bone marrow biopsies revealed ring granulomas consistent with EBV infection and a pattern of acute intrahepatic cholestasis indicative of potential drug-induced liver injury.\n\nThese findings suggested liver failure due to EBV infection, CAS and a possible oral contraceptive pill toxicity.\n\nDisease Management and Outcome\nBased on her diagnosis, the patient was admitted to the Hematology ward. For her hemolytic anemia, she underwent a first-line treatment with high dose methylprednisolone 1 mg/kg intravenously daily and immunoglobulin 1 g/kg intravenously for two days. However, a progressive worsening of general conditions occurred during hospitalization, developing hepatic failure with bilirubin levels rising to 43 mg/dL, hyperbilirubinemia-associated acute kidney injury, and respiratory failure requiring high-flow-nasal-cannula support. Consequently, she was transferred to the Intensive Care Unit (ICU), where she underwent central venous catheter placement due to poor venous access and her critical condition.\n\nGiven the complexity and the multifactorial etiology of the case, multiple clinical specialists were asked to carry out the best patient management. Initially, the patient was subjected to Plasorba BR-350 treatment, a selective adsorption mechanism for bilirubin and bile acid exceeding in plasma. Then, in consultation with nephrologists, continuous veno-venous hemofiltration (CVVH) was initiated to gradually improve kidney function.\n\nShe also started hepatoprotective therapy with ursodeoxycholic acid 300 mg orally twice daily, lactulose orally and K vitamin 10 mg intravenously daily.\n\nGiven her unresponsiveness to steroid therapy for hemolytic anemia and the concomitant EBV infection, in the context of secondary cold agglutinin syndrome, the patient received rituximab (375 mg/m2 weekly), a chimeric anti-CD20 monoclonal antibody effective against both disorders. Rituximab treatment proved effective in depleting EBV-infected B-lymphocytes and those involved in hemolytic pathogenesis.\n\nAfter a few weeks and four rituximab administrations, we observed a progressive amelioration of the patient clinical condition, with no more need of dialytic and respiratory support. She was gradually weaned off oxygen therapy, and her jaundice resolved along with normalization of liver function tests. After rituximab therapy, the EBV-DNA titer resulted negative, as also were cold agglutinin levels. Her hemoglobin level gradually returned to normal values.\n\nFinally, after one month of hospitalization, the patient was discharged in good general condition, with normal liver, renal and hemoglobin values.", + "fulltext_subclaims": [ + "The patient is a 20-year-old Caucasian female.", + "She visited the Emergency Department with complaints of fever, constant left abdominal pain, and generalized profuse fatigue.", + "The symptoms had occurred at rest few days before the ED admission.", + "She mentioned an episode of dysuria and fever ten days before, which had been treated with ciprofloxacin in the suspect of cystitis.", + "She reported having assumed three oral contraceptive pills containing ulipristal acetate in the 30 days before the symptom onset.", + "At the time of presentation, she denied nausea, diarrhea, or constipation.", + "She denied contact with animals, trips abroad, insect, or tick bites.", + "In January 2022, the patient had had SARS-CoV2 infection which had required anti-inflammatory therapy with ibuprofen and paracetamol without hospitalization.", + "She denied previous surgical interventions, autoimmune diseases, or chronic disease.", + "She reported no allergy toward drug and environmental allergens.", + "Her relatives had never suffered from liver or biliary disease.", + "She denied any relationship with hematologic disorders such as hemolytic anemia.", + "She confirmed no excessive assumption of alcohol.", + "She denied smoking cigarettes.", + "She reported a minimal physical activity as well as a high intake of sugar-containing beverages and food.", + "On admission, the patient’s initial vitals included blood pressure 100/60 mm Hg, pulse 75 beats per minute, respirations 15 breaths per minute, temperature 37.5°C, and an oxygen saturation of 98% on room air.", + "Physical examination revealed grade III obesity.", + "Physical examination revealed severe jaundice involving the muco-cutaneous surfaces and the sclerae.", + "No lymphadenopathies were palpable superficially.", + "The abdominal examination revealed mild upper left abdominal pain exacerbated by deep palpation, without tenderness.", + "Murphy and Courvoisier signs were absent.", + "Initial blood tests indicated leukocytosis with white blood cell (WBC) count 28460/mm3.", + "Initial blood tests indicated normochromic normocytic anemia with hemoglobin 7.9 g/dL.", + "Initial blood tests indicated platelets count (PLT) 212000/mm3.", + "Initial blood tests indicated hyperbilirubinemia with total serum bilirubin 23.11 mg/dL composed prevalently of direct bilirubin 19.36 mg/dL.", + "Initial blood tests indicated elevated liver function tests (ALT 244 U/L, AST 202 U/L).", + "Initial blood tests indicated cholestasis index (GGT 372 U/L, ALP 300 U/L).", + "Initial blood tests indicated C-reactive protein (CRP) 17 mg/dL.", + "Haptoglobin was depleted.", + "Lactate DeHydrogenase (LDH) was significantly elevated (3190 U/L).", + "The patient was tested for various infections, including HIV, hepatitis A, E, B, C viruses, cytomegalovirus, syphilis, West Nile virus, Plasmodium malariae, all returning negative results.", + "Abdominal ultrasonography and CT scan ruled out biliary obstruction or pancreatic disorders.", + "No evidence of autoimmune hepatitis was found.", + "EBV serology test showed a probable acute infection phase.", + "The infection acuity was confirmed by EBV DNA titer which was extremely high (123600 copies/mL).", + "The direct antiglobulin test for Complement 3 Factor (C3) and cold agglutinin test were positive.", + "Liver and bone marrow biopsies revealed ring granulomas consistent with EBV infection.", + "Liver and bone marrow biopsies revealed a pattern of acute intrahepatic cholestasis indicative of potential drug-induced liver injury.", + "These findings suggested liver failure due to EBV infection, CAS and a possible oral contraceptive pill toxicity.", + "The patient was admitted to the Hematology ward.", + "For her hemolytic anemia, she underwent a first-line treatment with high dose methylprednisolone 1 mg/kg intravenously daily and immunoglobulin 1 g/kg intravenously for two days.", + "A progressive worsening of general conditions occurred during hospitalization, developing hepatic failure with bilirubin levels rising to 43 mg/dL.", + "She developed hyperbilirubinemia-associated acute kidney injury.", + "She developed respiratory failure requiring high-flow-nasal-cannula support.", + "She was transferred to the Intensive Care Unit (ICU).", + "She underwent central venous catheter placement due to poor venous access and her critical condition.", + "The patient was subjected to Plasorba BR-350 treatment.", + "In consultation with nephrologists, continuous veno-venous hemofiltration (CVVH) was initiated.", + "She started hepatoprotective therapy with ursodeoxycholic acid 300 mg orally twice daily.", + "She started lactulose orally.", + "She received K vitamin 10 mg intravenously daily.", + "The patient received rituximab (375 mg/m2 weekly).", + "Rituximab treatment proved effective in depleting EBV-infected B-lymphocytes and those involved in hemolytic pathogenesis.", + "After a few weeks and four rituximab administrations, we observed a progressive amelioration of the patient clinical condition.", + "She was gradually weaned off oxygen therapy.", + "Her jaundice resolved along with normalization of liver function tests.", + "After rituximab therapy, the EBV-DNA titer resulted negative.", + "After rituximab therapy, cold agglutinin levels were negative.", + "Her hemoglobin level gradually returned to normal values.", + "After one month of hospitalization, the patient was discharged in good general condition.", + "At discharge, the patient had normal liver, renal and hemoglobin values." + ], + "summary": "We report on a unique case of life-threatening jaundice and hepatic failure in a 20-year-old female who presented to the emergency room with complaints of fever, constant left abdominal pain and generalized profuse fatigue. A complete and detailed medical history, multiple tests for various infection, radiologic investigations and histological tests were performed in order to clarify the etiology of that rapidly progressive clinical condition. Based on the results, the patient jaundice was caused by an Epstein-Barr virus (EBV) infection and secondary cold agglutinin syndrome. Given the rare and complex diagnosis, multiple clinical specialists were asked to carry out the best patient management.", + "summary_subclaims": [ + "The patient was a 20-year-old female.", + "The patient presented to the emergency room with complaints of fever.", + "The patient presented to the emergency room with complaints of constant left abdominal pain.", + "The patient presented to the emergency room with complaints of generalized profuse fatigue.", + "A complete and detailed medical history was performed.", + "Multiple tests for various infections were performed.", + "Radiologic investigations were performed.", + "Histological tests were performed.", + "The patient's jaundice was caused by an Epstein-Barr virus (EBV) infection.", + "The patient's jaundice was caused by secondary cold agglutinin syndrome.", + "Multiple clinical specialists were asked to carry out the best patient management." + ] + }, + { + "id": "multiclinsum_test_2505_en.txt", + "fulltext": "A 6-year-old child was admitted to the Eye Department of the Second Affiliated Hospital of Anhui Medical University (on June 3, 2017) with a complaint of ocular proptosis and no light perception after his tricycle had come to a sudden stop.\nHe was admitted to our department 4 h after the left eyeball was dislocated without any other facial injury after his tricycle had come to a sudden stop. He had pain in his left eye and experienced no light perception; moreover, his extraocular motility was limited.\nThe child and his grandfather denied any other medical conditions.\nThe child and his grandfather denied any family history of related diseases.\nUpon clinical examination, the patient presented with intact left globe luxation, exophthalmos (L/R = 5 mm), no visual acuity, no perception of light and a complete limitation of extraocular motility in all directions. The eyelid was intact, the conjunctiva showed hyperaemia, the cornea was dry and completely exposed and the pupil was mid-dilated, with no reaction to light . Furthermore, he could not keep his right eye open.\nNo laboratory tests.\nComputed tomography and magnetic resonance imaging showed proptosis of the left globe and gas accumulation in the superior intraconal space and stretching of the EOM . Magnetic resonance angiography excluded carotid cavernous fistula .", + "fulltext_subclaims": [ + "A 6-year-old child was admitted to the Eye Department of the Second Affiliated Hospital of Anhui Medical University on June 3, 2017.", + "The child had a complaint of ocular proptosis and no light perception.", + "The child was admitted 4 h after the left eyeball was dislocated.", + "The dislocation occurred after his tricycle had come to a sudden stop.", + "The child had pain in his left eye.", + "The child experienced no light perception.", + "The child's extraocular motility was limited.", + "The child and his grandfather denied any other medical conditions.", + "The child and his grandfather denied any family history of related diseases.", + "The patient presented with intact left globe luxation.", + "The patient had exophthalmos (L/R = 5 mm).", + "The patient had no visual acuity.", + "The patient had no perception of light.", + "The patient had a complete limitation of extraocular motility in all directions.", + "The eyelid was intact.", + "The conjunctiva showed hyperaemia.", + "The cornea was dry and completely exposed.", + "The pupil was mid-dilated, with no reaction to light.", + "Computed tomography and magnetic resonance imaging showed proptosis of the left globe.", + "Computed tomography and magnetic resonance imaging showed gas accumulation in the superior intraconal space.", + "Computed tomography and magnetic resonance imaging showed stretching of the EOM.", + "Magnetic resonance angiography excluded carotid cavernous fistula." + ], + "summary": "This report describes the treatment and prognosis of global luxation occurring in a child. A 6-year-old boy presented with left globe luxation that occurred after a sudden stop on a tricycle, without any injury to the orbital or maxillofacial bony structures. After admission to the hospital, an external canthus incision, globe repositioning, orbital exploration and temporary blepharoplasty were performed. Finally, the child completely recovered and maintained good eyesight in his left eye even though the right eye developed myopia after four years of follow-up.", + "summary_subclaims": [ + "This report describes the treatment and prognosis of global luxation occurring in a child.", + "A 6-year-old boy presented with left globe luxation.", + "The globe luxation occurred after a sudden stop on a tricycle.", + "There was no injury to the orbital or maxillofacial bony structures.", + "An external canthus incision was performed.", + "Globe repositioning was performed.", + "Orbital exploration was performed.", + "Temporary blepharoplasty was performed.", + "The child completely recovered.", + "The child maintained good eyesight in his left eye.", + "The right eye developed myopia after four years of follow-up." + ] + }, + { + "id": "multiclinsum_test_3325_en.txt", + "fulltext": "We present the clinical case of a 49-year-old male patient with a history of hypertension under treatment and smoking who consulted the emergency department for a 2-month-old picture of compromised general condition, significant weight loss, abdominal pain localized in the right hypochondrium and a non-quantified febrile sensation. On admission, a fever of 38°C, abdominal pain on deep palpation in the right hypochondrium and hepatomegaly were evident. In the admission laboratory, a normocytic-normokromic anaemia (Hb 11.2 g/gL, VCM 83 fL, HCM 27 pg) was evident; inflammatory parameters and leukocytosis with a left shift (leukocytes 24,900, absolute neutrophil count 19,860, PCR 156 mg/L, procalcitonin 5.1 ng/mL); elevated parameters of cholestasis (GGT 331 U/L, FA 267 U/L), discrete elevation of the transaminases (GPT 62 U/L, GOT 16 U/L) and total bilirubin levels (0.79 mg/dL) and direct (0.30 mg/dL) were normal. In addition, he presented a discrete shortening of the activated partial thromboplastin time (APTT 23.2 sec), with normal prothrombin and INR (PT 13.7 seconds, 78%, INR 1.15). Tumour markers (AFP < 1.3 ng/ml, ACE < 0.5 ng/ml) and blood cultures were negative.\n\nA computed tomography (CT) of the abdomen and pelvis with intravenous contrast (IVC) was requested, which showed a large solid mass in the left lobe of the liver, measuring approximately 6.6 cm in its major axis, and associated with hepatic hilar and portal-cavitary adenopathies. The study was complemented with an abdominal magnetic resonance (MRI) with IVC, which confirmed the hepatic mass, and was also associated with minimal dilation of the bile duct for that lobe. Its characteristics suggested a primary neoplastic lesion and, as a first possibility, an intrahepatic cholangiocarcinoma. In the context of the fever, elevated inflammatory parameters, cholestasis and dilation of the bile duct, the diagnosis of cholangitis was made, which was considered a tumor superinfection. Antibiotic treatment with Ceftriaxone and Metronidazole was initiated, with an adequate response, decreasing inflammatory parameters at 48 h.\n\nIn the face of the possibility of a highly aggressive neoplasm, such as intra-hepatic cholangiocarcinoma, in a patient with a low surgical risk and in whom a percutaneous biopsy with a negative result for malignancy could have corresponded to a false negative, it is decided in the first instance to resect the tumour completely. The patient undergoes an exploratory laparotomy, in order to rule out the involvement of the lymph nodes, in which case the tumour would be considered inoperable. The rapid biopsy of inter-cavo-aortic lymph nodes did not show any tumour involvement, so it was decided to carry out a segmentectomy (II and III), together with a lymphadenectomy of the loco-regional lymph nodes (porto-cavo space and the hepatic artery).\n\nThe histological result of the pieces studied informs that the hepatic tumor is composed of a lymphoplasmocytic inflammatory process, with immunoreactive plasma cells for CD138 and IgG, observing > 50 IgG4 positive plasma cells per field and some areas with IgG4/IgG ratio close to 40%, accompanied by stromal fibrosis. The rest of the ganglia do not present neoplastic pathology, observing expansion of the interfolicular zone, presence of numerous plasma cells, vascular hyperplasia, zones of involution of marginal centers and in the mantle zone, in addition to lymphocytes of disposition in concentric rings; morphological characteristics that can be found in the context of an IgG4-associated disease. The anatomical-pathological report is concluded as a diagnosis of a probable IgG4-associated disease (lymphoplasmocytic subtype). Serum IgG4 levels were not obtained.\n\nAs the tumor had already been resected, a wait-and-see approach was decided. The patient remains under follow-up to date (6 months after surgery) through clinical evaluation, laboratory tests and imaging control (abdominal MRI). He has shown a favorable evolution, remaining asymptomatic and without signs of local recurrence.\n", + "fulltext_subclaims": [ + "The patient is a 49-year-old male.", + "The patient has a history of hypertension under treatment.", + "The patient is a smoker.", + "The patient consulted the emergency department for a 2-month-old picture of compromised general condition.", + "The patient reported significant weight loss.", + "The patient reported abdominal pain localized in the right hypochondrium.", + "On admission, a fever of 38°C was recorded.", + "On admission, abdominal pain on deep palpation in the right hypochondrium was evident.", + "On admission, hepatomegaly was evident.", + "A normocytic-normokromic anaemia was evident on admission laboratory tests.", + "Hb was 11.2 g/gL.", + "VCM was 83 fL.", + "HCM was 27 pg.", + "Leukocytosis with a left shift was present.", + "Leukocytes were 24,900.", + "Absolute neutrophil count was 19,860.", + "PCR was 156 mg/L.", + "Procalcitonin was 5.1 ng/mL.", + "Elevated parameters of cholestasis were present.", + "GGT was 331 U/L.", + "FA was 267 U/L.", + "Discrete elevation of the transaminases was present.", + "GPT was 62 U/L.", + "GOT was 16 U/L.", + "Total bilirubin levels were 0.79 mg/dL.", + "Direct bilirubin was 0.30 mg/dL.", + "A discrete shortening of the activated partial thromboplastin time was present.", + "APTT was 23.2 sec.", + "Prothrombin time was 13.7 seconds.", + "INR was 1.15.", + "Tumour markers were negative.", + "AFP was < 1.3 ng/ml.", + "ACE was < 0.5 ng/ml.", + "Blood cultures were negative.", + "A computed tomography of the abdomen and pelvis with intravenous contrast was requested.", + "The CT showed a large solid mass in the left lobe of the liver.", + "The mass measured approximately 6.6 cm in its major axis.", + "The CT showed hepatic hilar and portal-cavitary adenopathies.", + "An abdominal magnetic resonance with intravenous contrast was performed.", + "The MRI confirmed the hepatic mass.", + "The MRI showed minimal dilation of the bile duct for that lobe.", + "The characteristics suggested a primary neoplastic lesion.", + "The first possibility was an intrahepatic cholangiocarcinoma.", + "The diagnosis of cholangitis was made.", + "The cholangitis was considered a tumor superinfection.", + "Antibiotic treatment with Ceftriaxone and Metronidazole was initiated.", + "The patient had an adequate response to antibiotics.", + "Inflammatory parameters decreased at 48 h.", + "The patient underwent an exploratory laparotomy.", + "The rapid biopsy of inter-cavo-aortic lymph nodes did not show any tumour involvement.", + "A segmentectomy (II and III) was carried out.", + "A lymphadenectomy of the loco-regional lymph nodes was performed.", + "The histological result showed a lymphoplasmocytic inflammatory process.", + "Immunoreactive plasma cells were observed for CD138 and IgG.", + "More than 50 IgG4 positive plasma cells per field were observed.", + "Some areas showed an IgG4/IgG ratio close to 40%.", + "Stromal fibrosis was present.", + "The rest of the ganglia did not present neoplastic pathology.", + "Expansion of the interfolicular zone was observed.", + "Numerous plasma cells were observed.", + "Vascular hyperplasia was observed.", + "Zones of involution of marginal centers were observed.", + "Lymphocytes of disposition in concentric rings were observed.", + "The anatomical-pathological report concluded as a diagnosis of a probable IgG4-associated disease (lymphoplasmocytic subtype).", + "Serum IgG4 levels were not obtained.", + "A wait-and-see approach was decided.", + "The patient remains under follow-up.", + "The patient has shown a favorable evolution.", + "The patient remains asymptomatic.", + "The patient has no signs of local recurrence." + ], + "summary": "We present the case of a 49-year-old male patient who consulted in the emergency department with a two-month history of illness characterized by general malaise, weight loss, abdominal pain, feverish feeling, and elevated inflammatory parameters. Imaging studies revealed a large liver lesion associated with dilated bile ducts and hepatic hilar, portal, and retroperitoneal (intercavitary-aortic) lymphadenopathy, which raised the suspicion of intrahepatic cholangiocarcinoma. Based on this suspicion, a segmental resection and regional lymphadenectomy was performed. Histopathological and immunohistochemical studies of the surgical specimen revealed a lymphoplasmocytic inflammatory process with the presence of IgG4-positive plasma cells, consistent with an IgG4-associated disease. After resection, expectant management was decided, and the patient had a favorable outcome, with no symptoms or signs of recurrence.\n", + "summary_subclaims": [ + "The patient is a 49-year-old male.", + "The patient had a two-month history of illness.", + "The patient reported general malaise.", + "The patient reported weight loss.", + "The patient reported abdominal pain.", + "The patient had a feverish feeling.", + "The patient had elevated inflammatory parameters.", + "Imaging studies revealed a large liver lesion.", + "Imaging studies showed dilated bile ducts.", + "Imaging studies showed hepatic hilar lymphadenopathy.", + "Imaging studies showed portal lymphadenopathy.", + "Imaging studies showed retroperitoneal (intercavitary-aortic) lymphadenopathy.", + "The imaging findings raised the suspicion of intrahepatic cholangiocarcinoma.", + "A segmental resection and regional lymphadenectomy was performed.", + "Histopathological and immunohistochemical studies revealed a lymphoplasmocytic inflammatory process.", + "Histopathological and immunohistochemical studies showed the presence of IgG4-positive plasma cells.", + "The findings were consistent with an IgG4-associated disease.", + "After resection, expectant management was decided.", + "The patient had a favorable outcome.", + "The patient had no symptoms or signs of recurrence." + ] + }, + { + "id": "multiclinsum_test_1537_en.txt", + "fulltext": "A 67-year-old male farmer presented to the Ophthalmology Unit of Obafemi Awolowo University Teaching Hospitals Complex in Ile-Ife, Nigeria, with a two-week history of pain, mucopurulent discharge and redness in the right eye. There was no history of foreign body entry into the right eye, nor was there ocular trauma or instillation of traditional eye medication. The patient had earlier used chloramphenicol eye drops which he obtained over the counter. His fasting blood sugar, complete blood count and electrolyte urea and creatinine were essentially normal for his age. The patient’s HIV status was negative on serology testing.\nFurther, ocular examination revealed a visual acuity of hand movement in the right eye, unaided and aided. Slit lamp biomicroscopic examination of the right eye showed a diffuse conjunctival hyperemia and a 5.5 x 4 mm corneal ulcer with raised and irregular margins which stained with fluorescein . Whitish stromal infiltrates were present in the ulcer bed and around the ulcer margins with associated stromal oedema and folds in the Descemet’s membrane. Anterior chamber examination revealed hypopyon of about one-eighth of the anterior chamber height. Pupil was round but sluggishly reactive to light and there was early lens opacity and no glow on fundoscopy in the right eye. Ocular findings in the left eye were essentially normal. A presumptive diagnosis of infective keratitis was made. During the slit lamp biomicroscopy, corneal scrapings were taken from the margins and the base of the ulcer and were sent to the microbiology and parasitology laboratory for bacterial and fungal tests. Direct lactophenol cotton blue mounts revealed septate fungal hyphae, while direct Gram stain showed cellular debris but no microorganisms. Culture on chocolate agar yielded scanty growth of cottony white colonies after 48 hours of incubation at 37°C. However, culture on Sabouraud dextrose agar at room temperature supported growth of woolly mould with reddish brown pigmentation on the agar after 48 hours . Lactophenol cotton blue staining of the mould under light microscope (x400 magnification) revealed conidiophores consisting of phialides, arranged in brush-like structures. Moreover, the phialides were cylindrical with small collarettes producing hyaline, smooth-walled conidia, which were arranged in masses. The macroconidia were septate, cylindrical with rounded apex and flat base . No bacteria were seen. The morphology of the mould identified was consistent with C. lichenicola.", + "fulltext_subclaims": [ + "The patient is a 67-year-old male farmer.", + "He presented with a two-week history of pain, mucopurulent discharge and redness in the right eye.", + "There was no history of foreign body entry into the right eye.", + "There was no ocular trauma.", + "There was no instillation of traditional eye medication.", + "The patient had earlier used chloramphenicol eye drops obtained over the counter.", + "Fasting blood sugar, complete blood count and electrolyte urea and creatinine were essentially normal for his age.", + "The patient’s HIV status was negative on serology testing.", + "Ocular examination revealed a visual acuity of hand movement in the right eye, unaided and aided.", + "Slit lamp biomicroscopic examination showed a diffuse conjunctival hyperemia.", + "A 5.5 x 4 mm corneal ulcer with raised and irregular margins was noted.", + "The ulcer stained with fluorescein.", + "Whitish stromal infiltrates were present in the ulcer bed and around the ulcer margins.", + "Anterior chamber examination revealed hypopyon of about one-eighth of the anterior chamber height.", + "Pupil was round but sluggishly reactive to light.", + "A presumptive diagnosis of infective keratitis was made.", + "Corneal scrapings were taken from the margins and the base of the ulcer.", + "Direct lactophenol cotton blue mounts revealed septate fungal hyphae.", + "Direct Gram stain showed cellular debris but no microorganisms.", + "Culture on chocolate agar yielded scanty growth of cottony white colonies after 48 hours of incubation at 37°C.", + "Culture on Sabouraud dextrose agar at room temperature supported growth of woolly mould with reddish brown pigmentation on the agar after 48 hours.", + "Lactophenol cotton blue staining of the mould under light microscope revealed conidiophores consisting of phialides, arranged in brush-like structures.", + "The phialides were cylindrical with small collarettes producing hyaline, smooth-walled conidia, which were arranged in masses.", + "The macroconidia were septate, cylindrical with rounded apex and flat base.", + "No bacteria were seen.", + "The morphology of the mould identified was consistent with C. lichenicola." + ], + "summary": "A 67-year-old farmer presented with a two-week history of pain, mucopurulent discharge, redness and a corneal ulcer with a visual acuity of hand movement in the right eye. With a working diagnosis of infective keratitis, corneal scrapings were taken under a slit lamp biomicroscope for microbiological testing. Direct lactophenol cotton blue mounts revealed septate fungal hyphae, while fungal culture on Sabouraud dextrose agar at room temperature grew woolly mould phenotypically consistent with C. lichenicola.", + "summary_subclaims": [ + "The patient is a 67-year-old farmer.", + "The patient had a two-week history of pain.", + "The patient had mucopurulent discharge.", + "The patient had redness.", + "The patient had a corneal ulcer.", + "The visual acuity was hand movement in the right eye.", + "The working diagnosis was infective keratitis.", + "Corneal scrapings were taken under a slit lamp biomicroscope.", + "Direct lactophenol cotton blue mounts revealed septate fungal hyphae.", + "Fungal culture on Sabouraud dextrose agar at room temperature grew woolly mould.", + "The growth was phenotypically consistent with C. lichenicola." + ] + }, + { + "id": "multiclinsum_test_60_en.txt", + "fulltext": "A 62-year-old man presented to his local hospital after 1 month of mucous and bloody stool and 2 weeks of worsening abdominal pain. He had leukocytosis (1.4 × 104/μL), thrombocytopenia (6.4 × 104/μL), and elevated blood urea nitrogen (BUN; 71 mg/dL) and serum creatinine (2.56 mg/dL) levels. The patient was admitted with a suspicion of sepsis secondary to intraabdominal infection, and broad-spectrum antimicrobial therapy was initiated. However, his condition deteriorated, and after 7 days, he was transferred to the intensive care unit (ICU) at Chiba University Hospital.\nOn admission to the ICU, the 165.3 cm tall patient weighing 99.3 kg was fully conscious (Glasgow Coma Scale E4V5M6), but he had a tendency to somnolence. His blood pressure was 154/103 mm Hg, heart rate 115/minutes, respiratory rate 30/minutes, body temperature 37.9 °C, and SpO2 96% on room air. The conjunctiva and skin were icteric. The chest was clear to auscultation. There was abdominal distention with mild hypogastric tenderness but no sign of peritoneal irritation. There was pitting edema in the upper and lower extremities. The white blood cell count was 1.2 × 104/μL, C-reactive protein level was 23.9 mg/dL, and procalcitonin level was 8.92 ng/mL, which were consistent with a diagnosis of bacterial infection. The platelet count had dropped to 3.8 × 104/μL, and the prothrombin time was 41% with a fibrin degradation product level of 53.1 μg/mL, indicative of coagulopathy. The lactate dehydrogenase level was 392 IU/L, aspartate transaminase and alanine transaminase levels were 50 and 17 IU/L, respectively, and also total and direct bilirubin levels were 6.2 and 4.6 mg/dL, respectively; however, other indicators of hemolysis, including anemia and schistocytosis, were absent. The BUN had increased to 92 mg/dL and the creatinine level was stable at 2.09 mg/dL. The CH50 level was 40.6 U/mL (normal range: 30–50 U/mL), the C3 level was 85 mg/dL (normal range: 65–135 mg/dL), and the C4 level was 23 mg/dL (normal range: 13–35 mg/dL).\nThe patient's clinical course is summarized in the Fig. . Since a stool culture test on ICU admission identified Enterococcus species and Corynebacterium striatum, a diagnosis of severe sepsis derived from bacterial enteritis was established and wide-spectrum antimicrobial therapy was initiated. Continuous hemodiafiltration was initiated on ICU day 3 but oliguria progressed to anuria, thrombocytopenia persisted, and laboratory values did not improve. Blood, urine, and spinal fluid cultures taken on admission to the ICU were all negative, which eliminated the possibility of additional foci of infection. Two polyps (one each in the sigmoid colon and the rectum) were discovered on lower gastrointestinal endoscopy, which were diagnosed at histopathology as early-stage nonhemorrhagic adenocarcinoma. The polyps did not appear to be the cause of the bloody stool. Additional laboratory evaluations were negative for other hematological disorders or connective tissue diseases. On ICU day 9, schistocytosis (0.5%) was noted on the peripheral blood smear, and a diagnosis of TMA was established. The Hct level also had dropped to 23.5% on the same day and the declining trend continued, therefore red blood cell transfusion was performed days later when he complained dyspnea. Plasma exchange (PE) therapy was initiated on ICU day 11. The patient had only a slight remission of thrombocytopenia after a total of 8 PE sessions (2.1 × 104/μL before the 1st PE and 5.9 × 104/μL after the 8th PE), but there was no notable clinical improvement and the anuria persisted . The level of ADAMTS13 activity in a plasma sample collected from the patient prior to initiation of PE was 25.1%, and the sample was negative for ADAMTS13 inhibitor. These findings eliminated the possibility of TTP. Furthermore, the stool was negative for Shiga toxin-producing-strains of Escherichia coli, and the serum titer for anti-Shiga-toxin antibody was also negative, eliminating the possibility of HUS. Although we considered TMA secondary to colorectal cancer in the differential diagnosis, the endoscopic findings of intramucosal carcinoma and negativity for tumor markers eliminated this possibility. Careful consideration of other possible causes, previous history, and drug history failed to identify an extrinsic etiology of TMA in this patient, and we ultimately suspected aHUS as the cause. Accordingly, intravenous eculizumab treatment (900 mg, once a week) was initiated on ICU day 26. An increase in urine output was observed on the next day, and renal support was successfully discontinued on the same day. And also marked recovery of the platelet count was obtained in combination with the effectiveness of supportive therapy including PE. Biweekly eculizumab infusion was repeated 4 times and then discontinued.\nAfter approval by the institutional review boards of Chiba University, the University of Tokyo, and National Cerebral and Cardiovascular Center, an anticomplement factor H (CFH) antibody assay and an analysis of complement factor H-related (CFHR) genes were performed using a blood sample collected from the patient prior to initiation of PE. Also written informed consent was obtained from the patient before the assays. The anti-CFH antibody level was 6.16 AU/mL, which indicated negativity for anti-CFH antibody. We performed the multiplex ligation-dependent probe amplification (MLPA) analysis to screen the copy numbers of CFHR1/3 on chromosome 1q32 using a commercially available kit (MLPA kit P236-A2; MRC-Holland, The Netherlands),[ and found that CFHR1/3 did not show gene deletions. However, moderate hemolysis was induced in concomitant hemolytic assays using sheep red blood cells (RBCs), and analysis for mutations potentially associated with aHUS identified a nonsynonymous mutation (p.Ala311Val) in the gene encoding membrane cofactor protein (MCP). All screened genes are presented in the Table .\nThe patient was discharged from the ICU on day 37 and was discharged to home on day 58. He was followed up regularly as an outpatient and was receiving 40 mg/day of prednisolone. At approximately 1 year after discharge, the patient remained in stable condition without relapse or resumption of eculizumab therapy.", + "fulltext_subclaims": [ + "The patient was a 62-year-old man.", + "He had 1 month of mucous and bloody stool.", + "He had 2 weeks of worsening abdominal pain.", + "He had leukocytosis (1.4 × 104/μL).", + "He had thrombocytopenia (6.4 × 104/μL).", + "He had elevated blood urea nitrogen (BUN; 71 mg/dL).", + "He had elevated serum creatinine (2.56 mg/dL).", + "He was admitted with a suspicion of sepsis secondary to intraabdominal infection.", + "Broad-spectrum antimicrobial therapy was initiated.", + "He was transferred to the ICU after 7 days.", + "On ICU admission, the patient was 165.3 cm tall.", + "On ICU admission, the patient weighed 99.3 kg.", + "On ICU admission, the patient was fully conscious (Glasgow Coma Scale E4V5M6).", + "On ICU admission, the patient had a tendency to somnolence.", + "On ICU admission, the white blood cell count was 1.2 × 104/μL.", + "On ICU admission, the C-reactive protein level was 23.9 mg/dL.", + "On ICU admission, the procalcitonin level was 8.92 ng/mL.", + "On ICU admission, the platelet count had dropped to 3.8 × 104/μL.", + "On ICU admission, the prothrombin time was 41%.", + "On ICU admission, the fibrin degradation product level was 53.1 μg/mL.", + "On ICU admission, the lactate dehydrogenase level was 392 IU/L.", + "On ICU admission, the aspartate transaminase level was 50 IU/L.", + "On ICU admission, the alanine transaminase level was 17 IU/L.", + "On ICU admission, the total bilirubin level was 6.2 mg/dL.", + "On ICU admission, the direct bilirubin level was 4.6 mg/dL.", + "On ICU admission, other indicators of hemolysis, including anemia and schistocytosis, were absent.", + "On ICU admission, the BUN had increased to 92 mg/dL.", + "On ICU admission, the creatinine level was stable at 2.09 mg/dL.", + "On ICU admission, the CH50 level was 40.6 U/mL.", + "On ICU admission, the C3 level was 85 mg/dL.", + "On ICU admission, the C4 level was 23 mg/dL.", + "A stool culture test on ICU admission identified Enterococcus species.", + "A stool culture test on ICU admission identified Corynebacterium striatum.", + "A diagnosis of severe sepsis derived from bacterial enteritis was established.", + "Wide-spectrum antimicrobial therapy was initiated.", + "Continuous hemodiafiltration was initiated on ICU day 3.", + "Blood, urine, and spinal fluid cultures taken on admission to the ICU were all negative.", + "Two polyps were discovered on lower gastrointestinal endoscopy.", + "The polyps were diagnosed at histopathology as early-stage nonhemorrhagic adenocarcinoma.", + "The polyps did not appear to be the cause of the bloody stool.", + "Additional laboratory evaluations were negative for other hematological disorders or connective tissue diseases.", + "On ICU day 9, schistocytosis (0.5%) was noted on the peripheral blood smear.", + "A diagnosis of TMA was established.", + "The Hct level had dropped to 23.5% on ICU day 9.", + "Plasma exchange (PE) therapy was initiated on ICU day 11.", + "The patient had only a slight remission of thrombocytopenia after a total of 8 PE sessions.", + "There was no notable clinical improvement after 8 PE sessions.", + "The anuria persisted.", + "The level of ADAMTS13 activity in a plasma sample collected from the patient prior to initiation of PE was 25.1%.", + "The sample was negative for ADAMTS13 inhibitor.", + "The findings eliminated the possibility of TTP.", + "The stool was negative for Shiga toxin-producing-strains of Escherichia coli.", + "The serum titer for anti-Shiga-toxin antibody was also negative.", + "The findings eliminated the possibility of HUS.", + "The endoscopic findings of intramucosal carcinoma and negativity for tumor markers eliminated the possibility of TMA secondary to colorectal cancer.", + "Careful consideration of other possible causes, previous history, and drug history failed to identify an extrinsic etiology of TMA in this patient.", + "We ultimately suspected aHUS as the cause.", + "Intravenous eculizumab treatment (900 mg, once a week) was initiated on ICU day 26.", + "An increase in urine output was observed on the next day.", + "Renal support was successfully discontinued on the same day.", + "Marked recovery of the platelet count was obtained in combination with the effectiveness of supportive therapy including PE.", + "Biweekly eculizumab infusion was repeated 4 times and then discontinued.", + "An anticomplement factor H (CFH) antibody assay and an analysis of complement factor H-related (CFHR) genes were performed.", + "The anti-CFH antibody level was 6.16 AU/mL.", + "The anti-CFH antibody level indicated negativity for anti-CFH antibody.", + "The MLPA analysis found that CFHR1/3 did not show gene deletions.", + "Moderate hemolysis was induced in concomitant hemolytic assays using sheep red blood cells.", + "Analysis for mutations potentially associated with aHUS identified a nonsynonymous mutation (p.Ala311Val) in the gene encoding membrane cofactor protein (MCP).", + "The patient was discharged from the ICU on day 37.", + "The patient was discharged to home on day 58.", + "He was followed up regularly as an outpatient.", + "He was receiving 40 mg/day of prednisolone.", + "At approximately 1 year after discharge, the patient remained in stable condition without relapse or resumption of eculizumab therapy." + ], + "summary": "Medical/surgical intensive care unit (ICU) of a university teaching hospital.A 62-year-old man presented to a local hospital with mucous and bloody stool persisting for 1 month and worsening abdominal pain for 2 weeks. He had thrombocytopenia and renal dysfunction and was admitted with a diagnosis of sepsis due to intraabdominal infection. However, he did not respond to antimicrobial therapy, and after 7 days he was transferred to the Chiba University Hospital ICU.Antimicrobial therapy was continued, and continuous hemodiafiltration was initiated on ICU day 3, but the patient's condition deteriorated and he became anuric. Plasma exchange (PE) was initiated on ICU day 11, but anuria and thrombocytopenia persisted. Intravenous eculizumab therapy was initiated on day 26 and resulted in quick recovery of urine output and platelet count and successful discontinuation of renal support.The diagnosis of thrombotic microangiopathy was established by the presence of schistocytes on the peripheral blood smear on ICU day 9. A plasma sample collected prior to initiation of PE showed a disintegrin-like and metalloproteinase with thrombospondin type 1 motifs member 13 (ADAMTS13) activity level of >10% (25.1%). The absence of both Shiga-toxin producing E coli in feces and anti-Shiga-toxin antibody in blood led to suspicion of atypical hemolytic uremic syndrome (aHUS). Genetic test identified a nonsynonymous mutation (p.Ala311Val) in the membrane cofactor protein gene (MCP).Although the pathological significance is currently unknown, this mutation may have been the cause of adult-onset aHUS in our patient. In this case, eculizumab was successfully introduced and discontinued, and the patient remained relapse-free after 1 year of follow-up. The duration of eculizumab therapy for patients with aHUS should be determined on a case-by-case basis and possibly according to the causative genetic mutation, even though discontinuation of eculizumab therapy once initiated is not generally recommended.", + "summary_subclaims": [ + "The patient was a 62-year-old man.", + "He presented with mucous and bloody stool persisting for 1 month.", + "He had worsening abdominal pain for 2 weeks.", + "He had thrombocytopenia.", + "He had renal dysfunction.", + "He was admitted with a diagnosis of sepsis due to intraabdominal infection.", + "He did not respond to antimicrobial therapy.", + "He was transferred to the Chiba University Hospital ICU after 7 days.", + "Antimicrobial therapy was continued.", + "Continuous hemodiafiltration was initiated on ICU day 3.", + "The patient's condition deteriorated.", + "He became anuric.", + "Plasma exchange was initiated on ICU day 11.", + "Anuria persisted.", + "Thrombocytopenia persisted.", + "Intravenous eculizumab therapy was initiated on day 26.", + "Eculizumab resulted in quick recovery of urine output.", + "Eculizumab resulted in quick recovery of platelet count.", + "Renal support was successfully discontinued.", + "The diagnosis of thrombotic microangiopathy was established by the presence of schistocytes on the peripheral blood smear on ICU day 9.", + "A plasma sample collected prior to initiation of PE showed an ADAMTS13 activity level of >10% (25.1%).", + "The absence of Shiga-toxin producing E coli in feces led to suspicion of atypical hemolytic uremic syndrome.", + "The absence of anti-Shiga-toxin antibody in blood led to suspicion of atypical hemolytic uremic syndrome.", + "A genetic test identified a nonsynonymous mutation (p.Ala311Val) in the membrane cofactor protein gene (MCP).", + "The pathological significance of the mutation is currently unknown.", + "The mutation may have been the cause of adult-onset aHUS in our patient.", + "Eculizumab was successfully introduced and discontinued.", + "The patient remained relapse-free after 1 year of follow-up.", + "The duration of eculizumab therapy for patients with aHUS should be determined on a case-by-case basis.", + "The duration of eculizumab therapy may be determined according to the causative genetic mutation.", + "Discontinuation of eculizumab therapy once initiated is not generally recommended." + ] + }, + { + "id": "multiclinsum_test_1524_en.txt", + "fulltext": "A 36-year-old male patient with severe continuous pain and swelling of tongue for 6 weeks was presented to Goba Referral Hospital. He is a farmer, married, and has two children. The swelling was 2 cm by 1 cm, located on posterior central tongue, and frank pus oozed from the center of swelling. The patient had associated dysphagia, odynophagia, and speech difficulty but no dyspnea. He had voluntary fixation of tongue because of pain. He had a history of left upper side and last molar tooth extraction before 10 years. Currently, he has been suffering from toothache and dental caries on the adjacent molar. He also had poor dental hygiene. The patient had no history of fever and chills. Additionally, he had no history of tongue bites or tongue trauma in the last 6 months. He had no previous personal and family history of similar illness and tonsillitis. The patient had no submandibular swelling, history of seizure, diabetic mellitus, hypertension, and retroviral infection. He had never eaten fish throughout his life but had consumed barley, milk, and sometimes wheat. The patient had no history of chewing chat, cigarette smoking, and drug use except for taking beer once per 1–2 months.\nBefore the patient visited our hospital, he was first treated at a health center where he was diagnosed with tonsillitis and was given amoxicillin 500 mg po tid (orally three times a day) for 7 days and paracetamol 1 g po prn. Although he showed mild improvement following treatment, the symptoms worsened after the completion of the course of antibiotics. Then, for the second time, the patient went to a private clinic where he was given augmentin 625 mg po bid for 7 days and tramadol 50 mg po prn. However, the patient was not relieved of pain and swelling.\nWith a diagnosis of pyogenic lingual abscess with lingual tuberculosis and tongue tumor as differential diagnosis, the patient was investigated. Random serum glucose level was 120 mg/dL, complete blood count was within normal range, and HIV antibody test was negative. Additionally, liver and renal function tests were done and found to be normal. Furthermore, venereal disease research laboratory test, and hepatitis B serum antigen and hepatitis C virus antibody tests were done and the results were negative.\nAn incision of 1 cm was made and 10 cc of thick frank pus was drained. A sample was taken from the drained pus and Gram staining was done; the report revealed Gram-positive cocci in clusters. However, acid fast bacilli test was negative. After drainage, augmentin 625 mg po tid for 7 days, metronidazole 500 mg po tid for 5 days, and diclofenac 50 mg po bid for 5 days was given, and the patient was relieved of pain after 48 hours of drug administration. The diagnostic difficulty in this patient was due to two reasons: 1) since lingual abscess is a very rare disease, patient was misdiagnosed in the health center as well as in the private clinic and 2) absence of culture and sensitivity service in our hospital. The patient was followed for 6 months and the condition did not relapse.", + "fulltext_subclaims": [ + "The patient is a 36-year-old male.", + "The patient had severe continuous pain and swelling of the tongue for 6 weeks.", + "The swelling was 2 cm by 1 cm, located on the posterior central tongue.", + "Frank pus oozed from the center of the swelling.", + "The patient had associated dysphagia, odynophagia, and speech difficulty.", + "The patient had no dyspnea.", + "The patient had a history of left upper side and last molar tooth extraction before 10 years.", + "The patient had toothache and dental caries on the adjacent molar.", + "The patient had poor dental hygiene.", + "The patient had no history of fever and chills.", + "The patient had no history of tongue bites or tongue trauma in the last 6 months.", + "The patient had no previous personal and family history of similar illness and tonsillitis.", + "The patient had no submandibular swelling.", + "The patient had no history of diabetic mellitus, hypertension, and retroviral infection.", + "The patient had never eaten fish throughout his life.", + "The patient had consumed barley, milk, and sometimes wheat.", + "The patient had no history of chewing chat, cigarette smoking, and drug use except for taking beer once per 1–2 months.", + "Before visiting the hospital, the patient was first treated at a health center.", + "At the health center, the patient was diagnosed with tonsillitis.", + "At the health center, the patient was given amoxicillin 500 mg po tid for 7 days.", + "At the health center, the patient was given paracetamol 1 g po prn.", + "The patient showed mild improvement following treatment at the health center.", + "The symptoms worsened after the completion of the course of antibiotics at the health center.", + "The patient then went to a private clinic.", + "At the private clinic, the patient was given augmentin 625 mg po bid for 7 days.", + "At the private clinic, the patient was given tramadol 50 mg po prn.", + "The patient was not relieved of pain and swelling after treatment at the private clinic.", + "With a diagnosis of pyogenic lingual abscess, the patient was investigated.", + "Lingual tuberculosis and tongue tumor were differential diagnoses.", + "Random serum glucose level was 120 mg/dL.", + "Complete blood count was within normal range.", + "HIV antibody test was negative.", + "Liver and renal function tests were done and found to be normal.", + "Venereal disease research laboratory test was done and the result was negative.", + "Hepatitis B serum antigen test was done and the result was negative.", + "Hepatitis C virus antibody test was done and the result was negative.", + "An incision of 1 cm was made and 10 cc of thick frank pus was drained.", + "A sample was taken from the drained pus and Gram staining was done.", + "Gram staining revealed Gram-positive cocci in clusters.", + "Acid fast bacilli test was negative.", + "After drainage, augmentin 625 mg po tid for 7 days was given.", + "After drainage, metronidazole 500 mg po tid for 5 days was given.", + "After drainage, diclofenac 50 mg po bid for 5 days was given.", + "The patient was relieved of pain after 48 hours of drug administration.", + "The diagnostic difficulty was due to lingual abscess being a very rare disease.", + "The diagnostic difficulty was due to the absence of culture and sensitivity service in the hospital.", + "The patient was followed for 6 months.", + "The condition did not relapse." + ], + "summary": "A 36-year-old male patient with severe, continuous pain and swelling of tongue for 6 weeks was presented to Goba Referral Hospital. The swelling was 2 cm by 1 cm, located on posterior central tongue, and frank pus oozed from the center of the swelling. He had associated dysphagia, odynophagia, and speech difficulty. He had no previous personal and family history of similar illness and tonsillitis. Gram staining revealed the presence of Gram-positive cocci in clusters. Pyogenic lingual abscess was the diagnosis. Treatment included incision and drainage with the administration of systemic antibiotics, which covered both aerobic and anaerobic organisms, and anti-pain drugs. The condition did not relapse in 6 months of follow-up.", + "summary_subclaims": [ + "The patient is a 36-year-old male.", + "The patient had severe, continuous pain and swelling of the tongue for 6 weeks.", + "The swelling was 2 cm by 1 cm.", + "The swelling was located on the posterior central tongue.", + "Frank pus oozed from the center of the swelling.", + "The patient had associated dysphagia.", + "The patient had associated odynophagia.", + "The patient had speech difficulty.", + "The patient had no previous personal history of similar illness.", + "The patient had no previous family history of similar illness.", + "The patient had no previous history of tonsillitis.", + "Gram staining revealed the presence of Gram-positive cocci in clusters.", + "The diagnosis was pyogenic lingual abscess.", + "Treatment included incision and drainage.", + "Systemic antibiotics were administered.", + "The antibiotics covered both aerobic and anaerobic organisms.", + "Anti-pain drugs were administered.", + "The condition did not relapse in 6 months of follow-up." + ] + }, + { + "id": "multiclinsum_test_2370_en.txt", + "fulltext": "A 67-year-old male patient was referred from the outpatient urologist for transurethral resection of the prostate (TUR-P) in September 2021 due to recurrent UTI. After treating the patient with several antibiotics, the urologist performed a cystoscopy, which revealed a bladder stone and an obstructive prostate. Finally, the patient was referred to our department for TUR-P. The initial hypothesis was, that the obstructive prostate caused the bladder stone. During the operation, parts of the stone were smashed and the prostate was resected. Furthermore, a prosthetic mesh eroding from the bladder roof was detected. The mesh was masqueraded by the stone. The pathological result ruled out any malignancy. A postoperative computed tomography scan revealed a 20 × 25 mm mesh migration into the bladder after inguinal hernia repair on the left with concomitant stone adhesion to the mesh. After revealing patient history, the inguinal hernia repair was performed 22 years ago.\nThe patient was admitted to robotic-assisted laparoscopic partial cystectomy with excision of the complete mesh and the stone . The procedure was performed using the “da Vinci X Surgical System” (Intuitive Surgical, Sunnyvale, CA). The patient was placed in Trendelenburg position. The operation was performed transperitoneal with a 12-mm camera port supraumbilical and three 8-mm trocars on a straight line. Additionally, one 8-mm port for the assistance was placed on the right. After partial resection of the bladder, the defect was closed with two-layer V-loc sutures (3.0). Lapra-Ty clips were attached at each suture for safety issues. Next a transurethral catheter was placed. No drainage was necessary due to the treating surgeon’s decision. The patient recovered well. After a normal cystography on postoperative day 7, the foley catheter was removed. The final pathological results revealed chronic fibrosis and mucosa inflammation of the bladder. After almost one year of follow-up the patient has no symptoms regarding hernia or voiding.", + "fulltext_subclaims": [ + "A 67-year-old male patient was referred for transurethral resection of the prostate in September 2021.", + "The patient had recurrent UTI.", + "The urologist performed a cystoscopy.", + "The cystoscopy revealed a bladder stone.", + "The cystoscopy revealed an obstructive prostate.", + "The initial hypothesis was that the obstructive prostate caused the bladder stone.", + "During the operation, parts of the stone were smashed.", + "The prostate was resected.", + "A prosthetic mesh eroding from the bladder roof was detected.", + "The mesh was masqueraded by the stone.", + "The pathological result ruled out any malignancy.", + "A postoperative computed tomography scan revealed a 20 × 25 mm mesh migration into the bladder.", + "The mesh migration was due to an inguinal hernia repair on the left.", + "The inguinal hernia repair was performed 22 years ago.", + "The patient was admitted to robotic-assisted laparoscopic partial cystectomy.", + "The procedure was performed using the “da Vinci X Surgical System”.", + "The patient was placed in Trendelenburg position.", + "The operation was performed transperitoneal.", + "A 12-mm camera port was placed supraumbilical.", + "Three 8-mm trocars were placed on a straight line.", + "One 8-mm port for assistance was placed on the right.", + "After partial resection of the bladder, the defect was closed with two-layer V-loc sutures.", + "Lapra-Ty clips were attached at each suture.", + "A transurethral catheter was placed.", + "No drainage was necessary.", + "The patient recovered well.", + "A normal cystography was performed on postoperative day 7.", + "The foley catheter was removed after a normal cystography.", + "The final pathological results revealed chronic fibrosis.", + "The final pathological results revealed mucosa inflammation of the bladder.", + "After almost one year of follow-up, the patient has no symptoms regarding hernia.", + "After almost one year of follow-up, the patient has no symptoms regarding voiding." + ], + "summary": "A 67-year-old male patient was referred from the outpatient urologist for transurethral resection of the prostate in September 2021 due to recurrent urinary tract infections caused by benign prostatic enlargement and bladder stone formation. During the operation, parts of the stone were smashed and the prostate was resected. Additionally, a mesh eroding from the bladder roof was detected masqueraded by the stone. A computed tomography scan, which was performed afterwards, revealed a 20 × 25 mm mesh migration into the bladder after inguinal hernia repair on the left with concomitant stone adhesion to the mesh. After revealing patient history, an inguinal hernia repair with mesh implantation was done 22 years ago. A robotic assisted partial cystectomy and mesh excision was performed. The patient recovered well.", + "summary_subclaims": [ + "The patient is a 67-year-old male.", + "The patient was referred for transurethral resection of the prostate in September 2021.", + "The reason for referral was recurrent urinary tract infections.", + "The urinary tract infections were caused by benign prostatic enlargement.", + "The urinary tract infections were also caused by bladder stone formation.", + "During the operation, parts of the stone were smashed.", + "The prostate was resected during the operation.", + "A mesh eroding from the bladder roof was detected.", + "The mesh was masqueraded by the stone.", + "A computed tomography scan was performed afterwards.", + "The computed tomography scan revealed a 20 × 25 mm mesh migration into the bladder.", + "The mesh migration was after an inguinal hernia repair on the left.", + "The mesh had concomitant stone adhesion.", + "An inguinal hernia repair with mesh implantation was done 22 years ago.", + "A robotic assisted partial cystectomy and mesh excision was performed.", + "The patient recovered well." + ] + }, + { + "id": "multiclinsum_test_1106_en.txt", + "fulltext": "A 45-year-old woman presented with a thyroid mass and thrombosis in a middle thyroid vein during a physical examination.\nThe patient came to hospital because of thyroid mass found in physical examination 3 mo before. She had no symptoms. The patient requested surgery because of the stress.\nThe patient was health in the past.\nThe patient had no family history of thyroid carcinoma and no history of radiation exposure in childhood.\nThe physical examination showed no positive signs.\nLaboratory tests showed that triiodothyronine, free triiodothyronine, thyroxine, thyroglobulin, and thyroid-stimulating hormone levels were within the normal limits.\nA solid nodule in the left lobe of the thyroid by ultrasound examination. Ultrasound examination revealed a medially echoic mass in the middle thyroid vein.\nSubsequent ultrasonography-guided fine-needle aspiration biopsy results indicated an atypical lesion of ambiguous significance, with some actively growing cells (TBSRTC III) and the BRAFV600E mutation not present.", + "fulltext_subclaims": [ + "A 45-year-old woman presented with a thyroid mass and thrombosis in a middle thyroid vein during a physical examination.", + "The patient came to hospital because of thyroid mass found in physical examination 3 mo before.", + "She had no symptoms.", + "The patient requested surgery because of the stress.", + "The patient was health in the past.", + "The patient had no family history of thyroid carcinoma.", + "The patient had no history of radiation exposure in childhood.", + "The physical examination showed no positive signs.", + "Laboratory tests showed that triiodothyronine, free triiodothyronine, thyroxine, thyroglobulin, and thyroid-stimulating hormone levels were within the normal limits.", + "A solid nodule in the left lobe of the thyroid by ultrasound examination.", + "Ultrasound examination revealed a medially echoic mass in the middle thyroid vein.", + "Subsequent ultrasonography-guided fine-needle aspiration biopsy results indicated an atypical lesion of ambiguous significance.", + "The BRAFV600E mutation was not present." + ], + "summary": "A 45-year-old woman presented with a thyroid mass and thrombosis in a middle thyroid vein during a physical examination. She had no symptoms, and the physical examination showed no positive signs. Subsequent ultrasonography-guided fine-needle aspiration biopsy results indicated an atypical lesion of ambiguous significance, with some actively growing cells (TBSRTC III) and the BRAFV600E mutation not present. This patient underwent left thyroidectomy, isthmus lobectomy, prophylactic central lymph node dissection and thromboembolectomy. Postoperative pathology showed papillary microcarcinoma of the left thyroid, and the thrombus in the middle thyroid vein was a tumor thrombus.", + "summary_subclaims": [ + "A 45-year-old woman presented with a thyroid mass.", + "She had thrombosis in a middle thyroid vein during a physical examination.", + "She had no symptoms.", + "The physical examination showed no positive signs.", + "Subsequent ultrasonography-guided fine-needle aspiration biopsy results indicated an atypical lesion of ambiguous significance.", + "The lesion was classified as TBSRTC III.", + "The BRAFV600E mutation was not present.", + "This patient underwent left thyroidectomy.", + "This patient underwent isthmus lobectomy.", + "This patient underwent prophylactic central lymph node dissection.", + "This patient underwent thromboembolectomy.", + "Postoperative pathology showed papillary microcarcinoma of the left thyroid.", + "The thrombus in the middle thyroid vein was a tumor thrombus." + ] + }, + { + "id": "multiclinsum_test_1512_en.txt", + "fulltext": "A 48-year-old caucasian woman (weighing 60 kg) was transferred from the emergency room (ER) of Boscotrecase (Naples, Italy) to the intensive care unit (ICU) of University of Campania “L. Vanvitelli” for suspected pyelonephritis with systemic impairment, fever, sepsis, and altered mental state (coma). She had no history of relevant comorbidities or particular risk factors such as immunosuppression.\nIn the ER, she underwent a computerized tomography (CT) scan of abdomen, chest, and brain with and without contrast enhancement. The CT scan demonstrated “moderate ectasia of the right renal calyx with peripheral medullar densitometric alterations,” being suggestive for pyelonephritis. On admission in our ICU, the patient was sedated, intubated with an orotracheal tube, monitored, and ventilated in a controlled mode. Vital signs on admission were arterial pressure 80/40 mmHg [mean arterial pressure (MAP), 53 mmHg]; heart rate 110 beats per minute (bpm), peripheral saturation of O2 (SpO2) 100%. Her body temperature was 39 °C; lactate values were 6.2 mmol/l. Right after admission, the patient’s monitoring was switched from noninvasive to invasive, with cannulation of the left radial artery and monitoring of hemodynamic parameters with the Vigileo system (a device that analyzes arterial blood pressure waveforms and their variations).\nThe hemodynamic parameters monitored with Vigileo showed cardiac output (CO) 2.1 l/minute (normal range 4.0–8.0 l/minute), systemic vascular resistance (SVR) 350 dyne seconds/cm5 (normal range 800–1200 dyne seconds/cm5) (MAP 53 mmHg).\nRoutine blood tests were performed, in addition to procalcitonin (PCT) sampling, serology for hepatotrophic viruses and human immunodeficiency virus (HIV), and a multiplex polymerase chain reaction (PCR) molecular biological blood sampling for detection of nucleic acids of bacteria, viruses, and fungi. Urine routine analysis along with microbiological tests was performed as well. A brief sedation window was performed, and neurological examination demonstrated a coma state with a Glasgow Coma Scale (GCS) score of 5 (Eye 1, Vocal 1T, Motor 3), with a decorticated response to pain, bilaterally myotic pupils with a torpid pupillary response, and a bilaterally positive Babinski sign.\nEarly fluid resuscitation began with a bolus of 30 ml/kg of crystalloid in 3 h, and norepinephrine infusion began at a rate of 0.2 µg/kg/minute [, ].\nEmpirical antibiotic therapy with ceftazole/tazobactam (1 g/0.5 g every 8 hours), meropenem (1 g every 8 hours), and aciclovir (250 mg) was administered. Dexamethasone was added as adjuvant therapy (10 mg once per day for 4 days) .\nBlood samples revealed white blood cells (WBC) 11.00 × 103/μl (normal range 4.2–9.0 × 103/µl) (neutrophils 86.0%, lymphocytes 12.6%), red blood cells (RBC) 3.97 × 106/μl (normal range 4.5–6.1 × 106/µl), hemoglobin (HB) 10.2 g/dl (normal range for women 12–16 g/dl), platelets (PLT) 54 × 103/μl (normal range 150–450 × 103/μl), procalcitonin (PCT) 61 ng/ml (normal range < 0.5 ng/ml), and C-reactive protein (CPR) 17.5 mg/dl (normal range < 0.5 mg/dl).\nFurthermore, blood PCR analysis was positive for E. coli. The analysis was negative for N. meningitidis, H. influenzae, and S. pneumoniae.\nUrine microbiological examination was also positive for E. coli, with a total microbial load (colony-forming units, CFU) of 10,000 CFU/ml. The antibiogram showed high sensitivity of E. coli to meropenem. We therefore decided to suspend ceftazole/tazobactam and continue therapy with meropenem.\nAfter etiologic diagnosis, in consideration of the septic shock condition and the relatively young age of the patient, it was decided to introduce an immunoglobilins (Ig)M-enriched intravenous immunoglobulin (IVIG) preparation (Pentaglobin®) at a dosage of 250 ml/kg per day for 4 days. Pentaglobin® (immunoglobulin IgM-enriched; Biotest) is a plasma-derived solution with the following composition: 12% IgM, 76% IgG, 12% IgA. Although the Surviving Sepsis Campaign guidelines advise against the use of IVIG in patients with sepsis or septic shock, given the lack of a statistical significance for survival benefits [, ], our recent positive outcome in treating septic shock with an IgM-enriched formulation as an adjuvant therapy and the Gram-negative etiology of the patient’s condition were a convincing rationale, as IgM-enriched IVIGs were found to have higher antibody levels against Escherichia\ncoli and other Gram-negative bacteria than did normal IVIG preparations .\nAfter 24 hours of therapy, the patient showed an improvement in blood chemistry (CPR 8.3 mg/dl; PCT 7.7 ng/ml; lactate 4.1 nmol/l) and hemodynamic parameters (CO 3.2 l/minute; SVR 550 dyne seconds/cm5, MAP 70 mmHg). Her body temperature was 36.5 °C. GCS score remained 5 (E1, V1T, M3) when another sedation window was performed. Her hemodynamic stability allowed her to undergo a brain magnetic resonance imaging (MRI) scan . The MRI scan revealed an altered signal and post-contrast enhancement of the leptomeninges. Moreover, multiple T2 and fluid-attenuated inversion recovery (FLAIR) hyperintense and sometimes confluent lesions were detected: in the thalamus, which appeared swollen; in the pons, in the cerebellar peduncles, and in cerebellar hemispheres, also appearing swollen; in the ventricles (mostly in the lateral ventricles and in the occipital horn bilaterally); and in the parahippocampal region bilaterally. All these lesions were also characterized by a reduced diffusivity in diffusion-weighted imaging (DWI) scans.\nFinally, multiple comminute T2/FLAIR white-matter hyperintense lesions were demonstrated, located in the juxtacortical white matter, especially in frontal regions, in both the corona radiata, and in periventricular regions bilaterally.\nAfter 48 hours from the start of Pentaglobin treatment, there was a remarkable improvement in hematochemical and hemodynamic parameters. In particular, the patient no longer needed inotropic support, and we therefore suspended continuous infusion of norepinephrine. Ventilation was switched to an assisted mode to wean the patient from the ventilator. Three days after admission, hemodynamic parameters of the patient were still improving, she was not febrile anymore, and lactate levels were dropping; on the other hand, her neurological condition was still severe, with a persistent altered mental state, bilateral miosis with a torpid papillary response, nystagmus, dyplegia with bilaterally positive Babinski sign and hyperelicitable osteotendinous reflexes.\n96 hours after Pentagoblin introduction, there was an evident improvement in the patient's clinical condition. GCS score increased to 10 (E3, V1T, M6). The patient was also able to be extubated, breathing spontaneously. Blood chemistry values were CPR 5.18 mg/dl, PCT 1.2 ng/ml, and lactate 1.2 mmol/l. Hemodynamic values were CO 5.4 l/minute, SVR 1200 dynes second/cm5, MAP 90 mmHg final. Neurological examination showed normal pupils and pupillary response, dyplegia with bilaterally positive Babinski sign, and hyperelicitable osteotendinous reflexes. Other cerebellar signs besides nystagmus became evident, with dysarthria and dysmetria of the upper limbs. A mild cognitive impairment was also detected, as the patient showed apraxia and executive functioning deficits. As the patient was more responsive, both a physiatrist and speech therapist assessment were scheduled to evaluate her and commence rehabilitation.\nSix days after admission, the patient underwent a control CT scan, which demonstrated a partial resolution of the renal alterations suggestive of pyelonephritis. She also underwent a control brain MRI on day 9 after admission. The MRI scan showed a reduction of all the previously detected lesions, with less swelling of the thalamus and cerebellum. On the other hand, the multiple juxtacortical and periventricular white-matter lesions remained substantially unchanged, also showing some microbleeding spots The patient remained in our department for the continuation of antimicrobial therapy and close monitoring. Twenty-one days after admission the patient was remarkably improved, showing only mild cerebellar signs (mostly dysarthria, along with dysmetria and a slight action tremor), slight hyposthenia of the four limbs, and mild apraxia on neurological examination. She was discharged and transferred to a rehabilitation center for post-intensive care rehabilitation to regain limb strength and coordination and to improve her speech abilities. Physiatrist, speech therapy, and neurological out-patient consultations, as well as a 6-month control brain MRI scan, were scheduled. Three months after discharge, a striking improvement of her condition was reported, as she was almost free from any neurological sign or symptom and almost fully recovered from her condition.", + "fulltext_subclaims": [ + "The patient was a 48-year-old caucasian woman weighing 60 kg.", + "She was transferred from the emergency room of Boscotrecase (Naples, Italy) to the ICU of University of Campania “L. Vanvitelli”.", + "The transfer was due to suspected pyelonephritis with systemic impairment, fever, sepsis, and altered mental state (coma).", + "She had no history of relevant comorbidities.", + "She had no history of particular risk factors such as immunosuppression.", + "In the ER, she underwent a CT scan of abdomen, chest, and brain with and without contrast enhancement.", + "The CT scan demonstrated moderate ectasia of the right renal calyx with peripheral medullar densitometric alterations.", + "The CT findings were suggestive for pyelonephritis.", + "On admission to the ICU, the patient was sedated, intubated with an orotracheal tube, monitored, and ventilated in a controlled mode.", + "Vital signs on admission included arterial pressure 80/40 mmHg, heart rate 110 bpm, SpO2 100%, body temperature 39 °C, and lactate 6.2 mmol/l.", + "The patient’s monitoring was switched from noninvasive to invasive with cannulation of the left radial artery.", + "Hemodynamic parameters were monitored with the Vigileo system.", + "Vigileo showed cardiac output 2.1 l/minute (normal range 4.0–8.0 l/minute).", + "Vigileo showed systemic vascular resistance 350 dyne seconds/cm5 (normal range 800–1200 dyne seconds/cm5).", + "Routine blood tests, procalcitonin sampling, serology, and PCR molecular biological blood sampling were performed.", + "Urine routine analysis and microbiological tests were performed.", + "A brief sedation window was performed.", + "Neurological examination demonstrated a coma state with a GCS score of 5 (Eye 1, Vocal 1T, Motor 3).", + "Early fluid resuscitation began with a bolus of 30 ml/kg of crystalloid in 3 h.", + "Norepinephrine infusion began at a rate of 0.2 µg/kg/minute.", + "Empirical antibiotic therapy included ceftazole/tazobactam, meropenem, and aciclovir.", + "Dexamethasone was added as adjuvant therapy at 10 mg once per day for 4 days.", + "Blood tests showed WBC 11.00 × 103/μl, neutrophils 86.0%, lymphocytes 12.6%.", + "Blood tests showed RBC 3.97 × 106/μl, hemoglobin 10.2 g/dl, platelets 54 × 103/μl.", + "Blood tests showed procalcitonin 61 ng/ml and C-reactive protein 17.5 mg/dl.", + "Blood PCR analysis was positive for E. coli.", + "Blood PCR analysis was negative for N. meningitidis, H. influenzae, and S. pneumoniae.", + "Urine microbiological examination was positive for E. coli with 10,000 CFU/ml.", + "The antibiogram showed high sensitivity of E. coli to meropenem.", + "Ceftazole/tazobactam was suspended, and therapy continued with meropenem.", + "An IgM-enriched IVIG preparation (Pentaglobin®) was introduced at 250 ml/kg per day for 4 days.", + "Pentaglobin® contains 12% IgM, 76% IgG, and 12% IgA.", + "The Surviving Sepsis Campaign guidelines advise against the use of IVIG in patients with sepsis or septic shock.", + "The rationale for IVIG use included recent positive outcomes with IgM-enriched formulations and Gram-negative etiology.", + "After 24 hours of therapy, CPR decreased to 8.3 mg/dl, PCT to 7.7 ng/ml, lactate to 4.1 nmol/l.", + "After 24 hours of therapy, CO increased to 3.2 l/minute, SVR to 550 dyne seconds/cm5, and MAP to 70 mmHg.", + "After 24 hours of therapy, body temperature was 36.5 °C.", + "A brain MRI scan was performed.", + "The MRI showed altered signal and post-contrast enhancement of the leptomeninges.", + "The MRI showed multiple T2 and FLAIR hyperintense lesions in the thalamus, pons, cerebellar peduncles, cerebellar hemispheres, ventricles, and parahippocampal regions.", + "The lesions showed reduced diffusivity in diffusion-weighted imaging.", + "Multiple comminute T2/FLAIR white-matter hyperintense lesions were detected in juxtacortical, frontal, corona radiata, and periventricular regions.", + "After 48 hours of Pentaglobin treatment, the patient no longer needed inotropic support.", + "Norepinephrine infusion was suspended.", + "Ventilation was switched to an assisted mode.", + "Three days after admission, lactate levels were dropping.", + "Neurological condition remained severe with persistent altered mental state.", + "96 hours after Pentaglobin introduction, GCS score increased to 10 (E3, V1T, M6).", + "The patient was extubated and breathing spontaneously.", + "Blood chemistry values showed CPR 5.18 mg/dl, PCT 1.2 ng/ml, lactate 1.2 mmol/l.", + "Hemodynamic values showed CO 5.4 l/minute, SVR 1200 dynes second/cm5, MAP 90 mmHg.", + "Neurological examination showed normal pupils and pupillary response.", + "Neurological examination showed dyplegia with bilaterally positive Babinski sign.", + "Neurological examination showed hyperelicitable osteotendinous reflexes.", + "Neurological examination showed dysarthria and dysmetria of the upper limbs.", + "Neurological examination showed mild cognitive impairment with apraxia and executive functioning deficits.", + "A control CT scan showed partial resolution of renal alterations.", + "A control brain MRI showed reduction of previously detected lesions with less swelling of the thalamus and cerebellum.", + "Multiple juxtacortical and periventricular white-matter lesions remained substantially unchanged.", + "Some microbleeding spots were detected.", + "The patient was discharged 21 days after admission.", + "She showed mild cerebellar signs, slight hyposthenia of the four limbs, and mild apraxia.", + "She was transferred to a rehabilitation center for post-intensive care rehabilitation.", + "Three months after discharge, she was almost free from neurological signs or symptoms.", + "She was almost fully recovered." + ], + "summary": "We describe the case of a 48-year-old caucasian woman with meningoencephalitis, with a marked alteration of consciousness on admission, and septic shock secondary to pyelonephritis caused by Escherichia coli, treated with targeted antimicrobial therapy and immunoglobulin-M-enriched immunoglobulin (Pentaglobin) preparation as adjuvant therapy.", + "summary_subclaims": [ + "The patient is a 48-year-old caucasian woman.", + "The patient had meningoencephalitis.", + "The patient had a marked alteration of consciousness on admission.", + "The patient had septic shock secondary to pyelonephritis.", + "The pyelonephritis was caused by Escherichia coli.", + "The patient was treated with targeted antimicrobial therapy.", + "The patient received immunoglobulin-M-enriched immunoglobulin (Pentaglobin) preparation as adjuvant therapy." + ] + }, + { + "id": "multiclinsum_test_3040_en.txt", + "fulltext": "A 61-year-old woman with PD for 17 months because of end-stage kidney disease caused by immunoglobin A nephropathy visited our hospital regularly with no major issues. The abrupt elevation of transaminase levels in blood test results was observed during a routine outpatient session. That day was designated as day 0. The patient was awake, with a blood pressure of 158/88 mmHg and a body temperature of 36.8 degrees Celsius. She showed no signs of fatigue, nausea, abdominal pain, diarrhea, or jaundice. The effluent of PD was not cloudy and ultrafiltration was not impaired. Blood test results revealed elevations of liver enzymes such as aspartate aminotransferase and alanine aminotransferase. On a computer tomography examination, we found a slightly enlarged liver suspected of liver injury. We did not perform a liver biopsy or ultrasound imaging. Since day −49, the patient has been receiving tolvaptan 7.5 mg/day for volume control as the only new medication. Although her liver function was normal as of day −49 and the next session on day −28, we suspected tolvaptan-induced liver injury. We immediately discontinued tolvaptan administration and consulted the Gastroenterology Department of our hospital. To further investigate the cause of liver injury, the blood screening test was positive for HEV-IgA, and the patient was diagnosed with HEV infection; other blood test results suggesting hepatic failure caused by viral and autoimmune hepatitis were negative.\n\nPatient comorbidities included hypertension, renal and iron deficiency anemia, insomnia, and restless legs syndrome. The patient had no experience with blood transfusion, and the patient’s family did not have any history of liver injury. She did not consume any apparent contaminated water or raw meat such as swine, deer, and wild boar. The patient had not visited any countries with a known risk of developing HEV infection. In terms of medications, the patient was taking tolvaptan 7.5 mg/day, furosemide 160 mg/day, trichlormethiazide 4 mg/day, pramipexole 0.25 mg/day, amlodipine 7.5 mg/day, telmisartan 80 mg/day, zolpidem 5 mg/day, lansoprazole 15 mg/day, epinastine 20 mg/day, lanthanum carbonate hydrate 1500 mg/day, evocalcet 2 mg/day, sodium ferrous citrate 50 mg/day, and Clostridium butyricum MIYAIRI. We did not treat her HEV infection because lowering transaminase levels were already observed when we diagnosed the HEV infection with positive HEV-IgA on day 14, with no new symptoms. Additionally, we did not resume the usage of tolvaptan after the development of HEV infection as tolvaptan did not increase the urinary volume. The patient’s hepatic failure has not relapsed as of day 91.", + "fulltext_subclaims": [ + "The patient is a 61-year-old woman.", + "She has PD for 17 months.", + "The PD is because of end-stage kidney disease.", + "The end-stage kidney disease is caused by immunoglobin A nephropathy.", + "She visited the hospital regularly with no major issues.", + "An abrupt elevation of transaminase levels was observed during a routine outpatient session.", + "That day was designated as day 0.", + "The patient was awake.", + "Her blood pressure was 158/88 mmHg.", + "Her body temperature was 36.8 degrees Celsius.", + "She showed no signs of fatigue.", + "She showed no signs of nausea.", + "She showed no signs of abdominal pain.", + "She showed no signs of diarrhea.", + "She showed no signs of jaundice.", + "The effluent of PD was not cloudy.", + "Ultrafiltration was not impaired.", + "Blood test results revealed elevations of liver enzymes such as aspartate aminotransferase and alanine aminotransferase.", + "A computer tomography examination found a slightly enlarged liver suspected of liver injury.", + "A liver biopsy was not performed.", + "An ultrasound imaging was not performed.", + "Since day −49, the patient has been receiving tolvaptan 7.5 mg/day.", + "Tolvaptan was the only new medication.", + "Her liver function was normal as of day −49.", + "Her liver function was normal as of day −28.", + "Tolvaptan-induced liver injury was suspected.", + "Tolvaptan administration was immediately discontinued.", + "The Gastroenterology Department was consulted.", + "The blood screening test was positive for HEV-IgA.", + "The patient was diagnosed with HEV infection.", + "Other blood test results suggesting hepatic failure caused by viral and autoimmune hepatitis were negative.", + "The patient had no experience with blood transfusion.", + "The patient’s family did not have any history of liver injury.", + "She did not consume any apparent contaminated water.", + "She did not consume any raw meat such as swine, deer, and wild boar.", + "She had not visited any countries with a known risk of developing HEV infection.", + "The patient was taking tolvaptan 7.5 mg/day.", + "The patient was taking furosemide 160 mg/day.", + "The patient was taking trichlormethiazide 4 mg/day.", + "The patient was taking pramipexole 0.25 mg/day.", + "The patient was taking amlodipine 7.5 mg/day.", + "The patient was taking telmisartan 80 mg/day.", + "The patient was taking zolpidem 5 mg/day.", + "The patient was taking lansoprazole 15 mg/day.", + "The patient was taking epinastine 20 mg/day.", + "The patient was taking lanthanum carbonate hydrate 1500 mg/day.", + "The patient was taking evocalcet 2 mg/day.", + "The patient was taking sodium ferrous citrate 50 mg/day.", + "The patient was taking Clostridium butyricum MIYAIRI.", + "The patient was not treated for HEV infection.", + "Lowering transaminase levels were already observed when HEV infection was diagnosed.", + "The patient did not resume the usage of tolvaptan after the development of HEV infection.", + "The patient’s hepatic failure has not relapsed as of day 91." + ], + "summary": "A 61-year-old woman with PD developed abrupt elevation of blood transaminase levels on a routine outpatient session. Since the patient has been receiving tolvaptan as the only new medication, we suspected tolvaptan induced liver injury. In further investigating the cause of liver injury, the blood screening test was found to be positive for HEV-IgA. The patient was diagnosed with HEV infection, and had a self-limited course.", + "summary_subclaims": [ + "The patient is a 61-year-old woman with PD.", + "The patient developed abrupt elevation of blood transaminase levels on a routine outpatient session.", + "The patient has been receiving tolvaptan as the only new medication.", + "We suspected tolvaptan induced liver injury.", + "The blood screening test was found to be positive for HEV-IgA.", + "The patient was diagnosed with HEV infection.", + "The patient had a self-limited course." + ] + }, + { + "id": "multiclinsum_test_299_en.txt", + "fulltext": "A 45-year-old Hispanic man with a 2-year history of progressive proptosis of the left eye attended to our center complaining of diplopia and hemicranial migraine. He was previously diagnosed with hyperthyroidism receiving thyrostatic treatment with thiamazole for 6 months without clinical improvement. His past medical history was not relevant, and he denied previous ocular trauma. At his arrival, physical examination revealed ptosis, palpebral edema, and exophthalmos of the left eye, as well as the abolishment of the ipsilateral photomotor and consensual responses, but conserving the corneal reflex. Furthermore, the patient presented an evident limitation for the abduction and supraduction of the affected eye, whereas fundoscopy showed mild optic atrophy. The exploration of the right eye did not reveal any abnormality, whereas the neurological examination showed normal cognitive function with no focal neurologic deficits. A T2-weighted magnetic resonance imaging (MRI) of the head showed a hyperintense mass arising at the superotemporal wall of the left orbit that was displacing the eyeball, invading the frontal bone, and causing inflammation of the adjacent dura mater .\nDue to the extension of the tumor, we decided on its surgical resection using a pterional approach. The skin incision and dissection of the temporalis muscle fascia were performed as described before [, ], in order to expose the temporal fossa and the orbital roof . To get access to the orbit, we performed the osteoplastic removal of the superolateral orbital wall (formed by the greater sphenoidal wing) using a surgical drill, with no need for opening the dura mater . This technical modification allowed us to completely resect a well-defined mass of hematic brown color, invading the frontal bone to the level of the frontozygomatic joint and the orbital floor, with minimal risk of lesioning intradural and orbital structures . The histopathological analysis of the resected tumor indicated the presence of abundant fibrous tissue, cholesterol crystals, coagulated hematic content, and a mixed inflammatory infiltrate with a predominance of lymphocytes and foamy histiocytes , compatible with the diagnosis of cholesteatoma. The patient recovered the functionality of the left eye with no deficits in the visual acuity nor diplopy , although he remained with a low degree of ptosis. Finally, a second MRI was performed, which showed no residual tumor 1-year after the surgery.", + "fulltext_subclaims": [ + "The patient is a 45-year-old Hispanic man.", + "He has a 2-year history of progressive proptosis of the left eye.", + "He complained of diplopia and hemicranial migraine.", + "He was previously diagnosed with hyperthyroidism.", + "He received thyrostatic treatment with thiamazole for 6 months.", + "There was no clinical improvement with thyrostatic treatment.", + "His past medical history was not relevant.", + "He denied previous ocular trauma.", + "Physical examination revealed ptosis of the left eye.", + "Physical examination revealed palpebral edema of the left eye.", + "Physical examination revealed exophthalmos of the left eye.", + "The ipsilateral photomotor response was abolished.", + "The consensual photomotor response was abolished.", + "The corneal reflex was conserved.", + "The patient had limitation for abduction of the affected eye.", + "Fundoscopy showed mild optic atrophy.", + "The right eye showed no abnormalities.", + "The neurological examination showed normal cognitive function.", + "The neurological examination showed no focal neurologic deficits.", + "A T2-weighted MRI showed a hyperintense mass arising at the superotemporal wall of the left orbit.", + "The mass was displacing the eyeball.", + "The mass was invading the frontal bone.", + "The mass was causing inflammation of the adjacent dura mater.", + "Surgical resection of the tumor was decided.", + "A pterional approach was used for the surgical resection.", + "The skin incision and dissection of the temporalis muscle fascia were performed.", + "The superolateral orbital wall was osteoplastically removed.", + "The superolateral orbital wall is formed by the greater sphenoidal wing.", + "The dura mater was not opened.", + "The resected mass was of hematic brown color.", + "The mass invaded the frontal bone to the level of the frontozygomatic joint.", + "The mass invaded the orbital floor.", + "The histopathological analysis showed abundant fibrous tissue.", + "The histopathological analysis showed cholesterol crystals.", + "The histopathological analysis showed coagulated hematic content.", + "The histopathological analysis showed a mixed inflammatory infiltrate.", + "The histopathological analysis showed a predominance of lymphocytes.", + "The histopathological analysis showed foamy histiocytes.", + "The histopathological findings were compatible with the diagnosis of cholesteatoma.", + "The patient recovered the functionality of the left eye.", + "There were no deficits in visual acuity.", + "Diplopia was resolved.", + "The patient remained with a low degree of ptosis.", + "A second MRI showed no residual tumor.", + "The second MRI was performed 1 year after the surgery." + ], + "summary": "A 45-year-old Hispanic man with a 2-year history of progressive proptosis of the left eye attended to our center complaining of diplopia and migraine. At his arrival, physical examination revealed ptosis, palpebral edema, and exophthalmos of the left eye, as well as the abolishment of the ipsilateral photomotor and consensual responses. Fundoscopy showed mild optic atrophy, whereas a T2-weighted magnetic resonance imaging (MRI) of the head showed a hyperintense mass arising at the superotemporal wall of the orbit that was displacing the eyeball. The tumor was resected using a pterional craniotomy without postoperative complications. The histopathological analysis of the tumor revealed a cholesteatoma. The patient recovered the functionality of the left eye with no visual sensitive deficits nor tumor recurrence 1 year after the surgery.", + "summary_subclaims": [ + "The patient is a 45-year-old Hispanic man.", + "He has a 2-year history of progressive proptosis of the left eye.", + "He complained of diplopia and migraine.", + "Physical examination revealed ptosis of the left eye.", + "Physical examination revealed palpebral edema of the left eye.", + "Physical examination revealed exophthalmos of the left eye.", + "The ipsilateral photomotor response was abolished.", + "The consensual response was abolished.", + "Fundoscopy showed mild optic atrophy.", + "A T2-weighted MRI of the head showed a hyperintense mass arising at the superotemporal wall of the orbit.", + "The tumor was resected using a pterional craniotomy.", + "There were no postoperative complications.", + "The histopathological analysis of the tumor revealed a cholesteatoma.", + "The patient recovered the functionality of the left eye.", + "There were no visual sensitive deficits 1 year after the surgery.", + "There was no tumor recurrence 1 year after the surgery." + ] + }, + { + "id": "multiclinsum_test_3052_en.txt", + "fulltext": "A 12-year-old male boy complained of crampy, lower abdominal pain that had been going on for four days. Additionally, he had a history of appetite loss, constipation, and mucoid diarrhoea. He also expressed abdominal distension, however, he had never vomited. No family history of similar symptoms was identified. He resides with his parents, three siblings, and grandparents. There were no recognized medical conditions in the child or his family.\n\nOn evaluation, the patient was acutely sick looking, appeared to be in severe agony. His vital sign was remarkable for tachycardia (pulse rate of 134 beats per minute), a respiratory rate of 22 breaths per minute, a temperature of 36.40°C, and a blood pressure of 110/75 millimetre of mercury. He lacked a depressed eyeball and had moist buccal mucosa. His abdomen was distended, moves with respiration, and tender everywhere else but the epigastrium. An 8 cm by 5 cm firm, tender mass across the left lower quadrant with the lowest boundary out of reach, and no evidence of fluid accumulation. The assessment of other systems was normal.\n\nInvestigations\nBlood tests were conducted which revealed a white blood cell count 10,300/micL with a neutrophilia of 78.5%, with moderate anemia (Hg 8.6 g/dl, Hct 28%), MCV 86 fl and platelet 775x103/micL. Ultrasound investigation identified a whirlpool sign at the splenic vessel, and the spleen is held in place in the lower abdomen with change in echogenicity. Wandering spleen with focal area infarction was the ultrasound diagnosis.\n\nTreatment and Outcome\nThe patient was kept nil by mouth and was put on maintenance fluid. He was started on broad-spectrum antibiotics and analgesia. After stabilizing the patient an emergency laparotomy was done. Intraoporately slightly enlarged spleen located intraperitoneally below the level of umbilicus. Vascular pedicle torsioned 720° was found unusually entering via the convexity of the spleen. Areas of necrosis apparent as soft pale patchy areas were noted. There was adhesion to the tip to appendix and loop of terminal ileum. There was no accessory spleen. Appendix tip was erythematous with petechial bleeding up on releasing from its adhesion to the spleen but the ileum was released from the adhesion uneventfully. With an intraoperative diagnosis of wandering spleen with multifocal infarction secondary to splenic volvulus plus secondarily inflammed appendix, splenectomy and appendectomy was done. Post-operative period is uneventful. He stayed for 2 hours in recovery and was then transferred to a surgical ward and stayed for seven days. After seven days stay, the patient was discharged with PO amoxicillin prophylaxis and appointed after a week for pneumococcal conjugate vaccine.", + "fulltext_subclaims": [ + "The patient is a 12-year-old male boy.", + "He complained of crampy, lower abdominal pain for four days.", + "He had a history of appetite loss.", + "He had a history of constipation.", + "He had mucoid diarrhoea.", + "He had abdominal distension.", + "He had never vomited.", + "There was no family history of similar symptoms.", + "He resides with his parents, three siblings, and grandparents.", + "There were no recognized medical conditions in the child or his family.", + "On evaluation, the patient was acutely sick looking.", + "He appeared to be in severe agony.", + "His pulse rate was 134 beats per minute.", + "His respiratory rate was 22 breaths per minute.", + "His temperature was 36.40°C.", + "His blood pressure was 110/75 millimetre of mercury.", + "He lacked a depressed eyeball.", + "He had moist buccal mucosa.", + "His abdomen was distended.", + "His abdomen moved with respiration.", + "His abdomen was tender everywhere else but the epigastrium.", + "An 8 cm by 5 cm firm, tender mass was found across the left lower quadrant.", + "The lowest boundary of the mass was out of reach.", + "There was no evidence of fluid accumulation.", + "The assessment of other systems was normal.", + "Blood tests revealed a white blood cell count of 10,300/micL.", + "Neutrophilia was 78.5%.", + "Hemoglobin was 8.6 g/dl.", + "Hematocrit was 28%.", + "MCV was 86 fl.", + "Platelet count was 775x103/micL.", + "Ultrasound identified a whirlpool sign at the splenic vessel.", + "The spleen was held in place in the lower abdomen with change in echogenicity.", + "The ultrasound diagnosis was wandering spleen with focal area infarction.", + "The patient was kept nil by mouth.", + "He was put on maintenance fluid.", + "He was started on broad-spectrum antibiotics.", + "He was started on analgesia.", + "An emergency laparotomy was done after stabilizing the patient.", + "Intraoperatively, a slightly enlarged spleen was located intraperitoneally below the level of umbilicus.", + "A vascular pedicle torsioned 720° was found entering via the convexity of the spleen.", + "Areas of necrosis were apparent as soft pale patchy areas.", + "There was adhesion to the tip of the appendix and loop of terminal ileum.", + "There was no accessory spleen.", + "The appendix tip was erythematous with petechial bleeding upon releasing from its adhesion to the spleen.", + "The ileum was released from the adhesion uneventfully.", + "The intraoperative diagnosis was wandering spleen with multifocal infarction secondary to splenic volvulus plus secondarily inflamed appendix.", + "Splenectomy and appendectomy were performed.", + "The post-operative period was uneventful.", + "He stayed for 2 hours in recovery.", + "He was transferred to a surgical ward.", + "He stayed for seven days in the surgical ward.", + "After seven days, the patient was discharged.", + "He was given PO amoxicillin prophylaxis.", + "He was appointed for a pneumococcal conjugate vaccine after a week." + ], + "summary": "A 12-year-old male child who had previously experienced constipation, mucoid diarrhoea, and abdominal distention arrived with crampy abdominal pain that had lasted for four days. The patient was tachycardic with abdominal tenderness. Whirlpool sign and lack of a spleen in its normal position were visualized on an abdominal ultrasound. The spleen was located intraoperatively in the lower abdomen, adhered to the ileum and appendix. It was 720° twisted and had necrotic areas. The patient underwent an appendectomy with splenectomy with a smooth post-operative course; combination meningococcal and pneumococcal vaccines were administered; and antibiotic prophylaxis was started for the patient.", + "summary_subclaims": [ + "The patient is a 12-year-old male child.", + "The patient had previously experienced constipation.", + "The patient had previously experienced mucoid diarrhoea.", + "The patient had previously experienced abdominal distention.", + "The patient arrived with crampy abdominal pain that had lasted for four days.", + "The patient was tachycardic.", + "The patient had abdominal tenderness.", + "Whirlpool sign was visualized on an abdominal ultrasound.", + "Lack of a spleen in its normal position was visualized on an abdominal ultrasound.", + "The spleen was located intraoperatively in the lower abdomen.", + "The spleen was adhered to the ileum and appendix.", + "The spleen was 720° twisted.", + "The spleen had necrotic areas.", + "The patient underwent an appendectomy with splenectomy.", + "The patient had a smooth post-operative course.", + "Combination meningococcal and pneumococcal vaccines were administered.", + "Antibiotic prophylaxis was started for the patient." + ] + }, + { + "id": "multiclinsum_test_1248_en.txt", + "fulltext": "A 56-year-old female was referred to our department from another facility in the patient’s area for a rapidly progressing tumor in the gallbladder and liver area. The patient reported several-month right upper quadrant pain and 4-kg weight loss over the past year. There was no laboratory sign of obstructive jaundice at the day of admission. Preoperative CT and MR scan of the liver was performed, and the patient was diagnosed with a tumor in the gallbladder area with a relatively massive infiltration of the S5 and S6 liver segments and extensive regions of necrosis. Given the potentially resectable lesion according to preoperative imaging, exploratory laparotomy was indicated to attempt radical resection. During the exploration, a voluminous tumor was found attached to the peritoneum. Intraoperative ultrasound was performed and revealed a tumor originating from the gallbladder bed area and reaching up to the area of the hepatic hilum and extensive involvement of the hepatoduodenal ligament by the tumor through the lymph nodes. The tumor was classified as inoperable due to this finding. But during the exploration, however, a rupture of the fragile tumor occurred with massive eruption of the necrotic mass and the gallbladder content into the abdominal cavity, accompanied by bleeding of the liver parenchyma. We decided that the condition could only be managed by attempting modified resection. We performed cholecystectomy and non-anatomical resection of hepatic segments S5 and S6 and partial resection of S4 without lymphadenectomy as a debulking operation . The course of hospitalization was uncomplicated, and the patient was discharged to home care on postoperative day 9. Histologically, the tumor was confirmed as MINEN of gallbladder , and its non-neuroendocrine component had the character of moderately differentiated tubular gall bladder adenocarcinoma, while the neuroendocrine component had the appearance of small cell carcinoma and was dominant, accounting for more than 65% of the viable tumor. The neuroendocrine component contained extensive necrosis, with mitotic index 64/10 HPF and a proliferation index of 70% . It was therefore obvious that the prognosis and the subsequent biological behavior would be influenced in particular by the neuroendocrine carcinoma component. Six weeks after the discharge, the patient underwent a follow-up CT scan prior to the initiation of systemic therapy, which revealed a large recurrence of the disease at the resection surface of the liver accompanied by hilar lymphadenopathy. The patient was started on systemic therapy with etoposide and carboplatin in combination with somatostatin analogues with very good radiological effect. We use this regimen as a standard in patients with MINEN of gastrointestinal tract with dominant neuroendocrine component, even with no somatostatin receptors staining available. Now the patient is almost a year after being diagnosed with a tumor, after completion of 6 cycles of adjuvant chemotherapy (carboplatin + etoposide) in combination with biological therapy, the long-acting somatostatin analogues. The patient is in good clinical condition, and while a recently performed PET/MRI scan revealed a hepatic lesion and hilar lymphadenopathy in full regression, there was a spread of small peritoneal and pleural metastases, with a solitary metastasis in Th9. The condition was evaluated as disease progression stage according to RECIST criteria, the patient remains in the follow-up care, and it is now 13 months after surgery .", + "fulltext_subclaims": [ + "A 56-year-old female was referred to our department from another facility in the patient’s area.", + "The patient reported several-month right upper quadrant pain.", + "The patient had 4-kg weight loss over the past year.", + "There was no laboratory sign of obstructive jaundice at the day of admission.", + "Preoperative CT and MR scan of the liver was performed.", + "The patient was diagnosed with a tumor in the gallbladder area with a relatively massive infiltration of the S5 and S6 liver segments.", + "The tumor had extensive regions of necrosis.", + "Given the potentially resectable lesion according to preoperative imaging, exploratory laparotomy was indicated.", + "During the exploration, a voluminous tumor was found attached to the peritoneum.", + "Intraoperative ultrasound revealed a tumor originating from the gallbladder bed area.", + "The tumor reached up to the area of the hepatic hilum.", + "The tumor had extensive involvement of the hepatoduodenal ligament by the tumor through the lymph nodes.", + "The tumor was classified as inoperable due to this finding.", + "A rupture of the fragile tumor occurred with massive eruption of the necrotic mass and the gallbladder content into the abdominal cavity.", + "The rupture was accompanied by bleeding of the liver parenchyma.", + "We decided that the condition could only be managed by attempting modified resection.", + "We performed cholecystectomy and non-anatomical resection of hepatic segments S5 and S6.", + "We performed partial resection of S4 without lymphadenectomy as a debulking operation.", + "The course of hospitalization was uncomplicated.", + "The patient was discharged to home care on postoperative day 9.", + "Histologically, the tumor was confirmed as MINEN of gallbladder.", + "The non-neuroendocrine component had the character of moderately differentiated tubular gall bladder adenocarcinoma.", + "The neuroendocrine component had the appearance of small cell carcinoma and was dominant, accounting for more than 65% of the viable tumor.", + "The neuroendocrine component contained extensive necrosis.", + "The mitotic index was 64/10 HPF.", + "The proliferation index was 70%.", + "Six weeks after the discharge, the patient underwent a follow-up CT scan.", + "The CT scan revealed a large recurrence of the disease at the resection surface of the liver.", + "The CT scan showed hilar lymphadenopathy.", + "The patient was started on systemic therapy with etoposide and carboplatin in combination with somatostatin analogues.", + "The regimen had a very good radiological effect.", + "We use this regimen as a standard in patients with MINEN of gastrointestinal tract with dominant neuroendocrine component.", + "The patient is almost a year after being diagnosed with a tumor.", + "The patient completed 6 cycles of adjuvant chemotherapy (carboplatin + etoposide) in combination with biological therapy.", + "The biological therapy included long-acting somatostatin analogues.", + "A recently performed PET/MRI scan revealed a hepatic lesion and hilar lymphadenopathy in full regression.", + "There was a spread of small peritoneal and pleural metastases.", + "There was a solitary metastasis in Th9.", + "The condition was evaluated as disease progression stage according to RECIST criteria.", + "The patient remains in the follow-up care.", + "It is now 13 months after surgery." + ], + "summary": "A 56-year-old female was referred to our department for a rapidly progressing tumor in the subhepatic area along with the infiltration of S5 and S6 liver segments. With regard to preoperative findings, the tumor appeared as operable, although, during the surgery, an extensive involvement of the hepatoduodenal ligament by the tumor through the lymph nodes was revealed. Due to acute perioperative bleeding from the necrotic tumor, we decided to perform modified resection. Histologically, the tumor was confirmed as MINEN of gallbladder, where the neuroendocrine component was dominant over the non-neuroendocrine component. Six weeks after the discharge, the patient underwent a follow-up CT revealing large recurrence of the disease. Thereafter, the patient was started on systemic therapy with etoposide and carboplatin in combination with somatostatin analogues. Thirteen months after the surgery, the patient is in good clinical condition, and while a recently performed PET/MRI scan revealed a hepatic lesion and hilar lymphadenopathy in full regression, there was a spread of small peritoneal and pleural metastases. The patient remains in the follow-up care.", + "summary_subclaims": [ + "The patient is a 56-year-old female.", + "The patient was referred for a rapidly progressing tumor in the subhepatic area.", + "The tumor infiltrated S5 and S6 liver segments.", + "The preoperative findings suggested the tumor was operable.", + "During surgery, an extensive involvement of the hepatoduodenal ligament by the tumor through the lymph nodes was revealed.", + "Acute perioperative bleeding from the necrotic tumor occurred.", + "A modified resection was performed.", + "Histologically, the tumor was confirmed as MINEN of gallbladder.", + "The neuroendocrine component was dominant over the non-neuroendocrine component.", + "Six weeks after discharge, a follow-up CT revealed large recurrence of the disease.", + "The patient was started on systemic therapy with etoposide and carboplatin in combination with somatostatin analogues.", + "Thirteen months after surgery, the patient is in good clinical condition.", + "A recently performed PET/MRI scan revealed a hepatic lesion and hilar lymphadenopathy in full regression.", + "There was a spread of small peritoneal and pleural metastases.", + "The patient remains in follow-up care." + ] + }, + { + "id": "multiclinsum_test_1564_en.txt", + "fulltext": "A 74-year-old male complained of blurred vision in both eyes because of senile cataract in October 2015. Visual acuities were 6/20 OD and 8/20 OS with a normal intraocular pressure (IOP). Slit-lamp examination revealed mild cortical cataract OU. Fundus findings showed nothing of note. The initial ophthalmologist planned to perform cataract surgery for his right eye. His medical history was prostate hypertrophy, while he had no history of dementia. Viscoelastic materials with high-level cohesion were injected into the anterior chamber to dilate the pupil due to miosis following hydrodissection OD. Severe thermal corneoscleral injury occurred soon after beginning the phacoemulsification. The wound was tightly sutured by pedunculated conjunctiva; however, viscoelastic materials were injected again since the leakage was not suppressed. The next day, he was referred to our hospital. Visual acuity was hand motion and IOP was 3 mm Hg OD. There was marked corneal stromal opacity with intraocular fluid leakage. The scleral wound was found to be opening following conjunctival incision . Since mobility of the sclera was markedly involved, it was impossible to conduct direct suture of the injured sclera. Therefore, the patient underwent transplantation of a donor scleral graft using 10-0 nylon to the burn site . After the transplantation and confirmation of the absence of intraocular fluid leakage, the lens nucleus was extracted from the newly formed wound on the temporal side of the scald. Histologically, the injured sclera showed coagulation necrosis with eosinophilic materials . Attachment of the transplanted sclera was favorable and IOP recovered to normal. Three months after the surgery, macular edema occurred due to intraocular inflammation caused by the remaining lens cortex. Therefore, anterior vitrectomy was conducted leading to the resolution of macular edema, and an intraocular lens was eventually fixed in the ciliary sulcus 7 months later. The visual acuity improved to 2/20 OD with stable IOP and a reduced corneal opacity in October 2016 .", + "fulltext_subclaims": [ + "The patient was a 74-year-old male.", + "He complained of blurred vision in both eyes because of senile cataract in October 2015.", + "Visual acuities were 6/20 OD and 8/20 OS.", + "Intraocular pressure was normal.", + "Slit-lamp examination revealed mild cortical cataract OU.", + "Fundus findings showed nothing of note.", + "The initial ophthalmologist planned to perform cataract surgery for his right eye.", + "He had a medical history of prostate hypertrophy.", + "He had no history of dementia.", + "Viscoelastic materials with high-level cohesion were injected into the anterior chamber to dilate the pupil due to miosis following hydrodissection OD.", + "Severe thermal corneoscleral injury occurred soon after beginning the phacoemulsification.", + "The wound was tightly sutured by pedunculated conjunctiva.", + "Viscoelastic materials were injected again since the leakage was not suppressed.", + "He was referred to our hospital the next day.", + "Visual acuity was hand motion OD.", + "Intraocular pressure was 3 mm Hg OD.", + "There was marked corneal stromal opacity with intraocular fluid leakage.", + "The scleral wound was found to be opening following conjunctival incision.", + "Mobility of the sclera was markedly involved.", + "It was impossible to conduct direct suture of the injured sclera.", + "The patient underwent transplantation of a donor scleral graft using 10-0 nylon to the burn site.", + "After the transplantation and confirmation of the absence of intraocular fluid leakage, the lens nucleus was extracted from the newly formed wound on the temporal side of the scald.", + "Histologically, the injured sclera showed coagulation necrosis with eosinophilic materials.", + "Attachment of the transplanted sclera was favorable.", + "Intraocular pressure recovered to normal.", + "Three months after the surgery, macular edema occurred due to intraocular inflammation caused by the remaining lens cortex.", + "Anterior vitrectomy was conducted leading to the resolution of macular edema.", + "An intraocular lens was eventually fixed in the ciliary sulcus 7 months later.", + "The visual acuity improved to 2/20 OD with stable IOP and a reduced corneal opacity in October 2016." + ], + "summary": "Severe thermal corneoscleral injury occurred during phacoemulsification in the right eye of a 74-year-old male. His medical history was prostate hypertrophy. Visual acuity was hand motion and the intraocular pressure was 3 mm Hg OD. There was heavy corneal stromal opacity with intraocular fluid leakage. The patient underwent transplantation of a donor scleral graft to the burn site. Histologically, the injured sclera showed coagulation necrosis without inflammatory cell infiltration. An intraocular lens was eventually fixed in the ciliary sulcus 7 months later. His visual acuity remains at 2/20 OD.", + "summary_subclaims": [ + "Severe thermal corneoscleral injury occurred during phacoemulsification in the right eye of a 74-year-old male.", + "His medical history was prostate hypertrophy.", + "Visual acuity was hand motion and the intraocular pressure was 3 mm Hg OD.", + "There was heavy corneal stromal opacity with intraocular fluid leakage.", + "The patient underwent transplantation of a donor scleral graft to the burn site.", + "Histologically, the injured sclera showed coagulation necrosis without inflammatory cell infiltration.", + "An intraocular lens was eventually fixed in the ciliary sulcus 7 months later.", + "His visual acuity remains at 2/20 OD." + ] + }, + { + "id": "multiclinsum_test_1565_en.txt", + "fulltext": "Fecal blood, diarrhea and thrombocytopenia over one year.\nA 1-year-old Chinese male patient with WAS was admitted for UCBT. He presented with fecal blood, diarrhea and thrombocytopenia at age 4 d, and was admitted to the West China Second University Hospital of Sichuan University. Admission to our hospital for hematopoietic stem cell transplantation.\nNone.\nNothing special.\nComplete blood count revealed that white blood cell (WBC) count was 13.64 × 109/L, hemoglobin 99 g/L, platelet count 7 × 109/L, and neutrophil count 3.53 × 109/L. Bone marrow (BM) aspiration revealed that the granulocyte/erythrocyte ratio was 0.7:1, thromocytogenic megakaryocyte 15/50, and platelets were deficient. WAS gene sequencing identified the mutation c.777 + 1G>A (IVS8).", + "fulltext_subclaims": [ + "The patient had fecal blood.", + "The patient had diarrhea.", + "The patient had thrombocytopenia.", + "The symptoms lasted over one year.", + "The patient was a 1-year-old Chinese male.", + "The patient was admitted for UCBT.", + "The patient was admitted to the West China Second University Hospital of Sichuan University.", + "The patient was admitted to our hospital for hematopoietic stem cell transplantation.", + "The WBC count was 13.64 × 109/L.", + "The hemoglobin was 99 g/L.", + "The platelet count was 7 × 109/L.", + "The neutrophil count was 3.53 × 109/L.", + "The granulocyte/erythrocyte ratio was 0.7:1.", + "The thrombocytogenic megakaryocyte count was 15/50.", + "Platelets were deficient.", + "WAS gene sequencing identified the mutation c.777 + 1G>A (IVS8)." + ], + "summary": "A 1-year-old Chinese male infant was diagnosed with WAS. WAS gene sequencing identified the mutation c.777 + 1G>A (IVS8). On August 8, 2017, he was admitted to our hospital for HSCT. We selected an unrelated Human leukocyte antigen 6/10-matched donor for UCBT. After HSCT, the immune reconstitution process was atypical, the lymphocytes reached 0.5 × 109/L on day 23, and the neutrophils reached 0.5 × 109/L on day 34. The patient's recovery throughout the year was good.", + "summary_subclaims": [ + "The patient was a 1-year-old Chinese male infant.", + "The patient was diagnosed with WAS.", + "WAS gene sequencing identified the mutation c.777 + 1G>A (IVS8).", + "The patient was admitted to the hospital for HSCT on August 8, 2017.", + "An unrelated Human leukocyte antigen 6/10-matched donor was selected for UCBT.", + "After HSCT, the immune reconstitution process was atypical.", + "Lymphocytes reached 0.5 × 109/L on day 23.", + "Neutrophils reached 0.5 × 109/L on day 34.", + "The patient's recovery throughout the year was good." + ] + }, + { + "id": "multiclinsum_test_338_en.txt", + "fulltext": "A 60-year-old female patient, known case of type-2 diabetes mellitus, began to experience pain and irritation in the left eye after undergoing a left penetrating keratoplasty.\nOn examination, the left lid was edematous, and the corneal graft showed edema with buried sutures. An infiltrate of 2 x 1.5 mm and an epithelial defect was observed temporally.\nThe visual acuity was limited to finger counting close to the face. Direct microscopy of a corneal scraping revealed septate hyphae, and fungal culture grew A. nidulans.\nThe patient was prescribed natamycin 5% and voriconazole eye drop 1% along with oral voriconazole 200 mg for 14 days. However, due to minimal resolution of infection,\nloose sutures were sent to the microbiology lab for a culture that again grew A. nidulans. The infection resolved after two months with an extended voriconazole treatment,\nand there have been no recurrences to date.\nA 65-year-old male farmer presented with diminution of vision and opacity in both eyes. He gave a history of redness and opacity in the right eye three years back and in the\nleft eye one month back. The patient had been diagnosed with right anterior staphyloma and corneal melt in the left eye in a private hospital when he referred to our center.\nThere was no history of ocular trauma, but a watery discharge and congestion were observed in both eyes. The visual acuity was limited to the perception of light in both eyes.\nThe left eye examination revealed a 3x3 mm central corneal thinning. The case was diagnosed with left infective keratitis with corneal thinning and melts.\nThe patient was empirically started on vancomycin 5%, tobramycin 1.3%, natamycin 5% eye drops, and oral ciprofloxacin for 14 days. On day 10 of presentation,\nthe ulcer in the left eye had a 2.5 x 2.5 mm perforation, for which penetrating keratoplasty (PK) was performed, and an intraoperatively excised cornea was\nsent for microbiological workup. The direct microscopy did not demonstrate any bacterial and fungal etiology. Therefore, the patient was discharged with\nan empirical coverage of vancomycin 5%, natamycin 5%, tobramycin 1.3% eye drops, and oral ciprofloxacin for 7 days and a plan for weekly follow up visits.\nThe fungal culture grew A. nidulans after 3 days. However, an oral antifungal could not be started as the patient did not visit the center again and was lost to follow-up.\nA 59-year-old male presented with sudden onset of vision diminution, pain, and redness in the left eye after undergoing cataract surgery five days earlier.\nThe visual acuity for distant vision in the left eye was hand movement close to the face. Ophthalmic examination showed conjunctival congestion and the presence of AC cells,\nexudates, and flare in the anterior chamber. A diagnosis of acute post-cataract surgery endophthalmitis was made. Subsequently, an Endophthalmitis Pars Plana Vitrectomy (PPV)\nwith intravitreal antibiotic instillation was performed. Vitreous biopsy was sent for microbiological workup, and the patient was discharged with\nan empirical coverage of vancomycin 5%, tobramycin eye drops 1.3% and oral ciprofloxacin for one week. Fungal culture grew A. nidulans.\nHowever, the patient did not refer for his first follow-up, and an antifungal could not be prescribed. The patient visited the center 18 days later due to the\ndeterioration of his condition, and the examination revealed a membrane on the left pupil along with a nasally located fungal ball.\nThe patient was operated for PPV with intraocular lens and bag explants, vitreous lavage, and intravitreal voriconazole (100μg /0.1ml) instillation along\nwith natamycin eye-drops 5%, and oral voriconazole 200 mg for one month.\nThe patient’s symptoms did not mitigate with the given treatment, and a diagnosis of recurrent endophthalmitis was made.\nThe PPV was repeated with intraocular lens and bag explants, accompanied with intravitreal amphotericin B (10μg /0.1ml) and vancomycin (1mg /0.1ml) instillation.\nThe patient could not visit the center for follow-up due to the COVID-19 pandemic. On teleconsultation, the patient reported left eye discharge, for which he was advised to follow up physically.\nSamples from all three cases were received in the ocular microbiology section. The samples included a corneal scraping and loose\nsutures (from case no. 1); cornea excised in PK procedure (from case no. 2); and two vitreous biopsies (from case no. 3).\nAll samples were processed for gram stain, potassium hydroxide (KOH) wet mount, and culture. Sheep Blood agar (5%) and Sabouraud Dextrose Agar (SDA)\n(HiMedia, Mumbai, India) were incubated at 37°C for 18 to 24 h and at 25°C for a minimum of 14 days. Primary microscopy of cases no. 1 and 3 showed thin\nbranching septate hyphae with few pus cells . Bacterial cultures were sterile in\nall three cases and SDA grew filamentous fungus between days 3 and 5. The isolation of fungi was considered significant if at least one\nof the following criteria was met: a) observation of fungal elements in primary microscopy and fungal growth in fungal culture medium (b)\nconfluent fungal growth on the sample inoculation site . The fungal growth from all samples was initially white cottony and later appeared glabrous. It matured with tan and smoky green alternative rings\non the obverse and dark brown pigment on the reverse . Lactophenol cotton blue staining showed septate\nhyaline hyphae with short to medium length brown-tinged conidiophores. These conidiophores produced biseriate, flask-shaped vesicles covered by metulae\nand phialides on the upper part bearing round, smooth, green conidia in chains .\nAfter 10-14 days, large round cleistothecia were observed encompassing asci producing red-brown lenticular ascospores .\nThe cleistothecia were surrounded by numerous large, spherical, thick, double-walled hyaline ‘Hulle Cells’ .\nThe morphological characteristics of the isolates were confirmed through slide cultures of all the isolates.\nThe E-strip method (HiMedia, Mumbai, India) was employed to determine the antifungal susceptibility pattern of all the isolates . Minimum Inhibitory Concentration (MIC) was determined for amphotericin B, posaconazole, itraconazole, and voriconazole using E-test strip.\nAll MIC values were recorded 24 and 48 h after the application of strips. The MIC was defined as the lowest concentration preventing\nany discernible growth. presents the results of the antifungal susceptibility test of the three isolates.\nClinical breakpoints (CBP) were not determined by the Clinical and Laboratory Standard Institute (CLSI) for Aspergillus species.\nTherefore, the results of antifungal susceptibility testing of amphotericin B, posaconazole, itraconazole, and voriconazole were interpreted following\nthe ‘modes’ (most frequent MIC) documented for Aspergillus spp. in the M38 document by CLSI .", + "fulltext_subclaims": [ + "A 60-year-old female patient, known case of type-2 diabetes mellitus, began to experience pain and irritation in the left eye after undergoing a left penetrating keratoplasty.", + "On examination, the left lid was edematous, and the corneal graft showed edema with buried sutures.", + "An infiltrate of 2 x 1.5 mm and an epithelial defect was observed temporally.", + "The visual acuity was limited to finger counting close to the face.", + "Direct microscopy of a corneal scraping revealed septate hyphae.", + "Fungal culture grew A. nidulans.", + "The patient was prescribed natamycin 5% and voriconazole eye drop 1% along with oral voriconazole 200 mg for 14 days.", + "Loose sutures were sent to the microbiology lab for a culture that again grew A. nidulans.", + "The infection resolved after two months with an extended voriconazole treatment.", + "There have been no recurrences to date.", + "A 65-year-old male farmer presented with diminution of vision and opacity in both eyes.", + "He gave a history of redness and opacity in the right eye three years back and in the left eye one month back.", + "The patient had been diagnosed with right anterior staphyloma and corneal melt in the left eye in a private hospital when he referred to our center.", + "There was no history of ocular trauma.", + "The visual acuity was limited to the perception of light in both eyes.", + "The left eye examination revealed a 3x3 mm central corneal thinning.", + "The case was diagnosed with left infective keratitis with corneal thinning and melts.", + "The patient was empirically started on vancomycin 5%, tobramycin 1.3%, natamycin 5% eye drops, and oral ciprofloxacin for 14 days.", + "On day 10 of presentation, the ulcer in the left eye had a 2.5 x 2.5 mm perforation, for which penetrating keratoplasty (PK) was performed.", + "The direct microscopy did not demonstrate any bacterial and fungal etiology.", + "The patient was discharged with an empirical coverage of vancomycin 5%, natamycin 5%, tobramycin 1.3% eye drops, and oral ciprofloxacin for 7 days.", + "The fungal culture grew A. nidulans after 3 days.", + "An oral antifungal could not be started as the patient did not visit the center again and was lost to follow-up.", + "A 59-year-old male presented with sudden onset of vision diminution, pain, and redness in the left eye after undergoing cataract surgery five days earlier.", + "The visual acuity for distant vision in the left eye was hand movement close to the face.", + "Ophthalmic examination showed conjunctival congestion and the presence of AC cells, exudates, and flare in the anterior chamber.", + "A diagnosis of acute post-cataract surgery endophthalmitis was made.", + "An Endophthalmitis Pars Plana Vitrectomy (PPV) with intravitreal antibiotic instillation was performed.", + "Vitreous biopsy was sent for microbiological workup.", + "The patient was discharged with an empirical coverage of vancomycin 5%, tobramycin eye drops 1.3% and oral ciprofloxacin for one week.", + "Fungal culture grew A. nidulans.", + "The patient did not refer for his first follow-up, and an antifungal could not be prescribed.", + "The patient visited the center 18 days later due to the deterioration of his condition.", + "The examination revealed a membrane on the left pupil along with a nasally located fungal ball.", + "The patient was operated for PPV with intraocular lens and bag explants, vitreous lavage, and intravitreal voriconazole (100μg /0.1ml) instillation along with natamycin eye-drops 5%, and oral voriconazole 200 mg for one month.", + "The patient’s symptoms did not mitigate with the given treatment, and a diagnosis of recurrent endophthalmitis was made.", + "The PPV was repeated with intraocular lens and bag explants, accompanied with intravitreal amphotericin B (10μg /0.1ml) and vancomycin (1mg /0.1ml) instillation.", + "The patient could not visit the center for follow-up due to the COVID-19 pandemic.", + "On teleconsultation, the patient reported left eye discharge, for which he was advised to follow up physically.", + "Samples from all three cases were received in the ocular microbiology section.", + "The samples included a corneal scraping and loose sutures (from case no. 1); cornea excised in PK procedure (from case no. 2); and two vitreous biopsies (from case no. 3).", + "All samples were processed for gram stain, potassium hydroxide (KOH) wet mount, and culture.", + "Sheep Blood agar (5%) and Sabouraud Dextrose Agar (SDA) were incubated at 37°C for 18 to 24 h and at 25°C for a minimum of 14 days.", + "Primary microscopy of cases no. 1 and 3 showed thin branching septate hyphae with few pus cells.", + "Bacterial cultures were sterile in all three cases.", + "SDA grew filamentous fungus between days 3 and 5.", + "The isolation of fungi was considered significant if at least one of the following criteria was met: a) observation of fungal elements in primary microscopy and fungal growth in fungal culture medium (b) confluent fungal growth on the sample inoculation site.", + "The fungal growth from all samples was initially white cottony and later appeared glabrous.", + "It matured with tan and smoky green alternative rings on the obverse and dark brown pigment on the reverse.", + "Lactophenol cotton blue staining showed septate hyaline hyphae with short to medium length brown-tinged conidiophores.", + "These conidiophores produced biseriate, flask-shaped vesicles covered by metulae and phialides on the upper part bearing round, smooth, green conidia in chains.", + "After 10-14 days, large round cleistothecia were observed encompassing asci producing red-brown lenticular ascospores.", + "The cleistothecia were surrounded by numerous large, spherical, thick, double-walled hyaline ‘Hulle Cells’.", + "The morphological characteristics of the isolates were confirmed through slide cultures of all the isolates.", + "The E-strip method was employed to determine the antifungal susceptibility pattern of all the isolates.", + "Minimum Inhibitory Concentration (MIC) was determined for amphotericin B, posaconazole, itraconazole, and voriconazole using E-test strip.", + "All MIC values were recorded 24 and 48 h after the application of strips.", + "The MIC was defined as the lowest concentration preventing any discernible growth.", + "Clinical breakpoints (CBP) were not determined by the Clinical and Laboratory Standard Institute (CLSI) for Aspergillus species.", + "The results of antifungal susceptibility testing of amphotericin B, posaconazole, itraconazole, and voriconazole were interpreted following the ‘modes’ documented for Aspergillus spp. in the M38 document by CLSI." + ], + "summary": "Three cases of ophthalmic infections, including two cases of keratitis and one case of recurrent endophthalmitis caused by A. nidulans were diagnosed at the ocular microbiology section of a tertiary eye care center. One case of keratitis had a history of ophthalmic surgery and underlying diabetes mellitus. The case of recurrent endophthalmitis had undergone cataract surgery in the recent past. Diminution of vision was the most common presenting feature in all three cases. The microbiological diagnosis was made by conventional microscopy and culture techniques.", + "summary_subclaims": [ + "Three cases of ophthalmic infections, including two cases of keratitis and one case of recurrent endophthalmitis caused by A. nidulans were diagnosed at the ocular microbiology section of a tertiary eye care center.", + "One case of keratitis had a history of ophthalmic surgery.", + "One case of keratitis had a history of underlying diabetes mellitus.", + "The case of recurrent endophthalmitis had undergone cataract surgery in the recent past.", + "Diminution of vision was the most common presenting feature in all three cases.", + "The microbiological diagnosis was made by conventional microscopy and culture techniques." + ] + }, + { + "id": "multiclinsum_test_2487_en.txt", + "fulltext": "A 12-year-old girl child presented with complaints of swelling around the nape of the neck associated with pain. The swelling, as reported by the parents, progressively increased in size over the period of 1 year. Pain was constant and dull aching in nature. Plain radiograph showed an expansile lytic lesion arising from the posterior elements of C2 vertebra . Accordingly, magnetic resonance imaging (MRI) was advised that showed multiple loculated lesions in the posterior elements of C2 that extended anteriorly to the body as well. There were fluid–fluid levels seen in most of the loculi. There was no extension into the spinal canal . Computed tomography (CT) scan reported expansile giant soap-bubble lesion with distorted trabeculae and thinning of cortices . Radiological appearances were consistent with ABC of C2 vertebrae. Subsequently, embolization of the feeder vessels to the lesion was done . Within 3 h of the procedure, navigated percutaneous biopsy was done under GA to prevent the patient movements during procedure. Tissue was sent for histopathology. Then, diluted contrast was injected into the lesion to confirm if there was any spinal canal leak. After ruling out any leak, methylprednisolone (120 mg) mixed with calcitonin (200 IU) was infiltrated into the lesion in different directions using navigation guided Jamshidi needle. Procedure was uneventful, and the child was sent home within 24 h. Histopathology showed numerous osteoclastic giant cells arranged non-spatially in spindle cell stroma with dissimilar nuclei. Blood-filled spaces rimmed by osteoclasts were seen. The appearance was suggestive of ABC . The patient was followed up in 2 months, and a repeat CT was done that showed few scattered calcifications along the trabeculae. She was further subjected to another session of selective feeder embolization followed by percutaneous intralesional injection of methylprednisolone and calcitonin in a similar fashion.\nIn view of COVID pandemic, patient’s parents were on telephonic contact who reported gradual reduction in pain and decrease in swelling size. She was followed up at the end of 18 months. Clinically, the pain had subsided with evident decrease in the size of the swelling. Repeat CT was done that showed dense ossification of the lesion, including the body of the vertebrae with significant shrinkage in fluid-filled cavities. There was reduction in the size of the lesion and spinal canal remained uninvolved .", + "fulltext_subclaims": [ + "A 12-year-old girl presented with swelling around the nape of the neck associated with pain.", + "The swelling progressively increased in size over the period of 1 year.", + "Pain was constant and dull aching in nature.", + "Plain radiograph showed an expansile lytic lesion arising from the posterior elements of C2 vertebra.", + "Magnetic resonance imaging (MRI) showed multiple loculated lesions in the posterior elements of C2.", + "There were fluid–fluid levels seen in most of the loculi.", + "There was no extension into the spinal canal.", + "Computed tomography (CT) scan reported expansile giant soap-bubble lesion with distorted trabeculae and thinning of cortices.", + "Radiological appearances were consistent with ABC of C2 vertebrae.", + "Embolization of the feeder vessels to the lesion was done.", + "Navigated percutaneous biopsy was done under GA within 3 h of the procedure.", + "Tissue was sent for histopathology.", + "Diluted contrast was injected into the lesion to confirm if there was any spinal canal leak.", + "Methylprednisolone (120 mg) mixed with calcitonin (200 IU) was infiltrated into the lesion.", + "The procedure was uneventful, and the child was sent home within 24 h.", + "Histopathology showed numerous osteoclastic giant cells arranged non-spatially in spindle cell stroma with dissimilar nuclei.", + "Blood-filled spaces rimmed by osteoclasts were seen.", + "The appearance was suggestive of ABC.", + "A repeat CT was done at 2 months that showed few scattered calcifications along the trabeculae.", + "The patient was subjected to another session of selective feeder embolization.", + "In view of the COVID pandemic, patient’s parents were on telephonic contact.", + "The parents reported gradual reduction in pain and decrease in swelling size.", + "The patient was followed up at the end of 18 months.", + "Clinically, the pain had subsided with evident decrease in the size of the swelling.", + "Repeat CT showed dense ossification of the lesion, including the body of the vertebrae with significant shrinkage in fluid-filled cavities.", + "There was reduction in the size of the lesion.", + "The spinal canal remained uninvolved." + ], + "summary": "A 12-year-old girl presented with pain and swelling around the nape of neck that increased in size over 1 year. Imaging and biopsy were suggestive of ABC. She was managed with selective embolization and percutaneous injection of methylprednisolone and calcitonin. Injections were given twice over 2 months period. At 1½ year follow-up, the patient was asymptomatic and swelling had shrunk in size and lesions ossified.", + "summary_subclaims": [ + "The patient is a 12-year-old girl.", + "She presented with pain and swelling around the nape of the neck.", + "The swelling increased in size over 1 year.", + "Imaging and biopsy were suggestive of ABC.", + "She was managed with selective embolization.", + "She received percutaneous injection of methylprednisolone.", + "She received percutaneous injection of calcitonin.", + "Injections were given twice over a 2-month period.", + "At 1½ year follow-up, the patient was asymptomatic.", + "At 1½ year follow-up, the swelling had shrunk in size.", + "At 1½ year follow-up, the lesions had ossified." + ] + }, + { + "id": "multiclinsum_test_399_en.txt", + "fulltext": "A 64-year-old female was admitted to our center due to an incidental mobile abdominal mass.\nPrior to admission, the patient noticed an increase in her abdominal size, which she construed as weight gain.\nOn physical examination, a large non-tender mobile mass was palpated in the right abdomen.\nLaboratory examinations showed a cancer antigen 125 (CA125) level of 540.6 U/mL (normal range < 35 U/mL).\nContrast-enhanced abdominal computed tomography (CT) revealed a huge mass measuring 25.4 cm × 23.0 cm with a mixed density and heterogeneous enhancement . CT three-dimensional (3D) reconstruction showed that the feeding arteries were from the splenic artery and celiac axis . From the imaging findings, we suspected a gastrointestinal stromal tumor (GIST).", + "fulltext_subclaims": [ + "The patient is a 64-year-old female.", + "The patient was admitted due to an incidental mobile abdominal mass.", + "Prior to admission, the patient noticed an increase in her abdominal size.", + "On physical examination, a large non-tender mobile mass was palpated in the right abdomen.", + "The cancer antigen 125 (CA125) level was 540.6 U/mL.", + "Contrast-enhanced abdominal CT revealed a huge mass measuring 25.4 cm × 23.0 cm with a mixed density and heterogeneous enhancement.", + "CT three-dimensional reconstruction showed that the feeding arteries were from the splenic artery and celiac axis.", + "From the imaging findings, we suspected a gastrointestinal stromal tumor." + ], + "summary": "A 64-year-old female presented with an abdominal mass, and underwent exploratory surgery, during which a huge tumor originating from the greater omentum and intraperitoneal implants were identified and resected. The results of the pathological examination, immunohistochemistry staining, and gene sequencing led to the diagnosis of malignant SFT of the greater omentum. The patient died one and a half years later due to tumor recurrence and metastasis.", + "summary_subclaims": [ + "The patient was a 64-year-old female.", + "The patient presented with an abdominal mass.", + "The patient underwent exploratory surgery.", + "A huge tumor originating from the greater omentum was identified during surgery.", + "Intraperitoneal implants were identified during surgery.", + "The tumor was resected.", + "The results of the pathological examination were part of the diagnostic process.", + "Immunohistochemistry staining was performed.", + "Gene sequencing was performed.", + "The diagnosis was malignant SFT of the greater omentum.", + "The patient died one and a half years later.", + "The patient's death was due to tumor recurrence and metastasis." + ] + }, + { + "id": "multiclinsum_test_474_en.txt", + "fulltext": "A 54-year-old Caucasian woman complained of an unpleasant taste and pain in the mouth. Her medical history included breast cancer with metastasis, which was diagnosed in 2007. The patient had no comorbidities and no history of smoking. A radical mastectomy with axillary dissection was performed. The patient had no previous history of radiotherapy of the head and neck or use of bisphosphonates. The patient received bevacizumab (400 mg/16 mL every 2 weeks; 32 infusions in total) from 11 April 2014 to 26 October 2016. Docetaxel (30 mg/m2 on D1 and D15 of the cycle) and carboplatin (386 mg on D1 and D15 of the cycle) infusions were started in April 2014 and suspended in September 2016. The patient’s leukocyte count was 4310 cells/mm3 (segmented neutrophils, 1896/mm3; band neutrophils, 0/mm3). At 28 days following suspension of the cancer treatment, intraoral clinical examination revealed drainage of purulent secretion involving teeth 16, 25, 27, 44, and 47 . Cone-beam computed tomography (CT) showed the association of hypodense areas with the remaining roots of teeth 16, 25, and 27, and disruption of the lower cortical regions of the maxillary sinus. Hypodense areas could also be seen associated with the roots of teeth 44 and 47 . The patient did not present with clinical characteristics or radiographic findings to suggest MRONJ, and dental implant was placed on 19 December 2016 (3 months after suspension of her medication). At 54 days after the last dose of bevacizumab, and on completion of 3 months of docetaxel and carboplatin infusions, debridement and dental extractions of teeth 16, 25, 27, 44, and 47 were performed in combination with immediate insertion of Straumann® Bone Level Tapered-BLT® implants (SLActive) in regions of teeth 44, 45, 46, and 47 . Chlorhexidine 0.12% mouth wash and levofloxacin (Levoxin®) were prescribed 5 days before and after the oral implantation surgery and continued 5 days after the implantation surgery.\nFive weeks postoperatively, pain, drainage of purulent secretion, and bone exposure around the implants were observed , although none of the implants showed mobility. Ten ozone therapy sessions associated with levofloxacin were performed. After 4 weeks of therapy with ozone oil (Philozon®, Balneário Camboriú, SC, Brazil), no pain or drainage of purulent secretion were present. Bone sequestration accompanied by implant mobility could, however, be seen. Local debridement and implant removal were performed.\nThe material removed consisted of 3 irregular fragments of hard, brown bone tissue, with the largest measuring 1.0 × 1.0 × 0.3 cm and the smallest measuring 0.4 × 0.4 × 0.3 cm. The material was stained with hematoxylin and eosin, and histological sections revealed irregular fragments consisting of devitalized bone and the presence of osteoclasts. Adjacent to the necrotic trabeculae, fibrous connective tissue exhibiting intense mixed inflammatory infiltrates (neutrophils, lymphocytes, plasma cells, and some macrophages) was found. Bacterial colonies and hemorrhagic foci were also noted . Based on these results, the histological examination indicated osteonecrosis, categorized as stage 2 MRONJ .\nAt 14 days after debridement, the alveolar ridge was completely covered by soft tissue without bone exposure, and the patient was no longer experiencing pain. In March 2017, after the resolution of the osteonecrosis, the patient underwent the same chemotherapy regimen (bevacizumab, carboplatin, and docetaxel) as administered earlier. In July 2017, the patient was still undergoing chemotherapy. At the 7-month postoperative follow-up, the debrided area presented a healthy mucosal covering without lesions . No signs of bone lysis or sequestration were seen on the panoramic radiograph .", + "fulltext_subclaims": [ + "The patient was a 54-year-old Caucasian woman.", + "She complained of an unpleasant taste and pain in the mouth.", + "Her medical history included breast cancer with metastasis diagnosed in 2007.", + "The patient had no comorbidities.", + "She had no history of smoking.", + "A radical mastectomy with axillary dissection was performed.", + "The patient had no previous history of radiotherapy of the head and neck.", + "The patient had no previous history of use of bisphosphonates.", + "She received bevacizumab (400 mg/16 mL every 2 weeks; 32 infusions in total) from 11 April 2014 to 26 October 2016.", + "Docetaxel (30 mg/m2 on D1 and D15 of the cycle) infusions were started in April 2014.", + "Carboplatin (386 mg on D1 and D15 of the cycle) infusions were started in April 2014.", + "Docetaxel and carboplatin infusions were suspended in September 2016.", + "The patient’s leukocyte count was 4310 cells/mm3.", + "Intraoral clinical examination at 28 days following suspension of cancer treatment revealed drainage of purulent secretion involving teeth 16, 25, 27, 44, and 47.", + "Cone-beam CT showed hypodense areas associated with the remaining roots of teeth 16, 25, and 27.", + "Cone-beam CT showed disruption of the lower cortical regions of the maxillary sinus.", + "Hypodense areas could also be seen associated with the roots of teeth 44 and 47.", + "The patient did not present with clinical characteristics or radiographic findings to suggest MRONJ.", + "A dental implant was placed on 19 December 2016.", + "Debridement and dental extractions of teeth 16, 25, 27, 44, and 47 were performed.", + "Immediate insertion of Straumann® Bone Level Tapered-BLT® implants (SLActive) in regions of teeth 44, 45, 46, and 47 was performed.", + "Chlorhexidine 0.12% mouth wash was prescribed 5 days before and after the oral implantation surgery.", + "Levofloxacin was prescribed 5 days before and after the oral implantation surgery.", + "Five weeks postoperatively, pain, drainage of purulent secretion, and bone exposure around the implants were observed.", + "None of the implants showed mobility.", + "Ten ozone therapy sessions associated with levofloxacin were performed.", + "After 4 weeks of therapy with ozone oil, no pain or drainage of purulent secretion were present.", + "Bone sequestration accompanied by implant mobility could be seen.", + "Local debridement and implant removal were performed.", + "The material removed consisted of 3 irregular fragments of hard, brown bone tissue.", + "The largest fragment measured 1.0 × 1.0 × 0.3 cm.", + "The smallest fragment measured 0.4 × 0.4 × 0.3 cm.", + "Histological sections revealed irregular fragments consisting of devitalized bone.", + "The presence of osteoclasts was noted.", + "Adjacent to the necrotic trabeculae, fibrous connective tissue exhibiting intense mixed inflammatory infiltrates was found.", + "Bacterial colonies were noted.", + "Hemorrhagic foci were noted.", + "The histological examination indicated osteonecrosis.", + "The histological examination categorized the osteonecrosis as stage 2 MRONJ.", + "At 14 days after debridement, the alveolar ridge was completely covered by soft tissue without bone exposure.", + "The patient was no longer experiencing pain.", + "In March 2017, after the resolution of the osteonecrosis, the patient underwent the same chemotherapy regimen as administered earlier.", + "In July 2017, the patient was still undergoing chemotherapy.", + "At the 7-month postoperative follow-up, the debrided area presented a healthy mucosal covering without lesions.", + "No signs of bone lysis or sequestration were seen on the panoramic radiograph." + ], + "summary": "A 54-year-old female patient with a history of metastatic breast cancer and bevacizumab use presented with a dental infection. Dental extraction followed immediately by dental implant placement was planned after suspension of the bevacizumab treatment. The patient presented with pain, drainage of purulent secretion, and bone exposure 5 weeks post-surgery. Complete healing was achieved at postoperative 7 months.", + "summary_subclaims": [ + "The patient is a 54-year-old female.", + "The patient has a history of metastatic breast cancer.", + "The patient had been using bevacizumab.", + "The patient presented with a dental infection.", + "Dental extraction followed immediately by dental implant placement was planned.", + "Bevacizumab treatment was suspended before the planned surgery.", + "The patient presented with pain 5 weeks post-surgery.", + "The patient had drainage of purulent secretion 5 weeks post-surgery.", + "The patient had bone exposure 5 weeks post-surgery.", + "Complete healing was achieved at postoperative 7 months." + ] + }, + { + "id": "multiclinsum_test_2684_en.txt", + "fulltext": "Our patient is a 40-year-old P1332 who presented for prenatal care with dating ultrasound confirming viable intrauterine pregnancy at 6.5 weeks. Her medical history was notable for type 2 diabetes, chronic hypertension, severe preeclampsia, and intrauterine fetal demise in a previous pregnancy. She received routine prenatal care and was started on medication for her co-morbidities. First trimester cfDNA resulted “low risk” for fetal trisomies though was “no call,” or unable to ascertain the risk for monosomy X or sex chromosome aneuploidy. Targeted anatomy ultrasound at 22 weeks revealed a singleton fetus with normal anatomy, a normal fetal echocardiogram, and a normal appearing anterior placenta. Additional images showed a 12 cm by 7 cm area of multi-cystic placental tissue in the uterine fundus concerning for possible molar tissue versus placental mesenchymal dysplasia.\nRepeat cfDNA testing, using single nucleotide polymorphism-based next-generation sequencing, reported results consistent with a possible triploid, vanishing twin, or unrecognized multiple gestation. The report also noted suspected complete uniparental disomy, which is most consistent with a molar pregnancy. She received genetic counseling and declined amniocentesis for diagnostic testing.\nShe was asymptomatic and had normal vital signs. Labs were notable for a significantly elevated hCG over 250,000, subclinical hyperthyroidism, and normal hepatic function. Chest x-ray was negative for metastatic disease. She was counseled by a multidisciplinary team including Maternal Fetal Medicine (MFM) and Gynecologic Oncology regarding expectant management versus uterine evacuation. Despite the serious health risks posed by continuation of her pregnancy, pregnancy termination was not available in her state as her gestational age at the time of diagnosis was greater than the gestational age ban limit of 20 weeks post conception. Counseling did include the ability to explore termination care in other states with later gestational age limits, though given the legal restrictions in place she could not be directly referred or transferred if she desired termination care . Her options were further limited by the additional barriers of out-of-pocket costs for the procedure, travel, lodging, and childcare. She elected to proceed with expectant management and was co-managed by MFM and Gynecologic Oncology. Delivery was scheduled for no later than 32 weeks after consensus conference, but she ultimately developed severe preeclampsia at 31 weeks necessitating delivery. Following counseling, the patient desired to proceed with cesarean hysterectomy given she did not desire future fertility and she was counseled about a decreased risk of post-molar conversion to GTN following hysterectomy compared to uterine evacuation. Her case was uncomplicated with total EBL 1300 cc. Other than blood pressure elevations in the setting of severe preeclampsia, her post-operative course was uncomplicated and she discharged home on post-operative day four. APGARs were 1, 6, and 8, and the neonatal course was complicated by prematurity and respiratory distress requiring a 19-day NICU stay.\nHistology revealed an intact unremarkable placental disc loosely adherent to the posterior uterine wall, together with a tan-pink, spongy cystic mass densely adherent to the right uterine wall measuring 13.5 cm by 7.7 cm by 2.6 cm (A). Sections of tissue demonstrate a tan friable cut surface with focal myometrial invasion (B). Hematoxylin and eosin slides show a complete hydatidiform mole displaying intrauterine implantation with focal extension of a molar villous into the superficial myometrium, which is diagnostic of invasive hydatidiform mole (A and 2B). There was complete absence of immunohistochemical staining for p57 in the molar villi and hyperplastic trophoblast, which confirmed the diagnosis of complete hydatidiform mole (C). Additionally, there is a distinct interface identified without invasion into the normal placental disc (D). Based on her WHO score and FIGO stage 1 disease she was low risk for recurrence or progression and was followed with serial hCGs. Her hCG nadir was 8.0 before rising two months after delivery, consistent with post-molar GTN. She has since finished 4 cycles of single agent Actinomycin D, receiving 3 cycles of chemotherapy past a negative hCG. She is now 8 months from treatment with no evidence of disease by exam and serially negative hCG testing.", + "fulltext_subclaims": [ + "The patient is a 40-year-old P1332.", + "A dating ultrasound confirmed a viable intrauterine pregnancy at 6.5 weeks.", + "Her medical history included type 2 diabetes.", + "Her medical history included chronic hypertension.", + "Her medical history included severe preeclampsia.", + "Her medical history included intrauterine fetal demise in a previous pregnancy.", + "First trimester cfDNA resulted 'low risk' for fetal trisomies.", + "First trimester cfDNA was 'no call' for monosomy X.", + "First trimester cfDNA was 'no call' for sex chromosome aneuploidy.", + "Targeted anatomy ultrasound at 22 weeks revealed a singleton fetus with normal anatomy.", + "Targeted anatomy ultrasound at 22 weeks showed a normal fetal echocardiogram.", + "Targeted anatomy ultrasound at 22 weeks showed a normal appearing anterior placenta.", + "Additional images showed a 12 cm by 7 cm area of multi-cystic placental tissue in the uterine fundus.", + "Repeat cfDNA testing used single nucleotide polymorphism-based next-generation sequencing.", + "Repeat cfDNA testing reported results consistent with a possible triploid.", + "Repeat cfDNA testing reported results consistent with a possible vanishing twin.", + "Repeat cfDNA testing reported results consistent with a possible unrecognized multiple gestation.", + "The report noted suspected complete uniparental disomy.", + "The report noted suspected complete uniparental disomy, which is most consistent with a molar pregnancy.", + "She received genetic counseling.", + "She declined amniocentesis for diagnostic testing.", + "She was asymptomatic.", + "She had normal vital signs.", + "Labs were notable for a significantly elevated hCG over 250,000.", + "Labs were notable for subclinical hyperthyroidism.", + "Labs were notable for normal hepatic function.", + "Chest x-ray was negative for metastatic disease.", + "She was counseled by a multidisciplinary team including Maternal Fetal Medicine (MFM) and Gynecologic Oncology.", + "Pregnancy termination was not available in her state as her gestational age at the time of diagnosis was greater than the gestational age ban limit of 20 weeks post conception.", + "Counseling included the ability to explore termination care in other states with later gestational age limits.", + "Given the legal restrictions in place, she could not be directly referred or transferred if she desired termination care.", + "Her options were further limited by the additional barriers of out-of-pocket costs for the procedure, travel, lodging, and childcare.", + "She elected to proceed with expectant management.", + "She was co-managed by Maternal Fetal Medicine and Gynecologic Oncology.", + "Delivery was scheduled for no later than 32 weeks after consensus conference.", + "She ultimately developed severe preeclampsia at 31 weeks necessitating delivery.", + "Following counseling, the patient desired to proceed with cesarean hysterectomy.", + "She did not desire future fertility.", + "She was counseled about a decreased risk of post-molar conversion to GTN following hysterectomy compared to uterine evacuation.", + "Her case was uncomplicated with total EBL 1300 cc.", + "Other than blood pressure elevations in the setting of severe preeclampsia, her post-operative course was uncomplicated.", + "She was discharged home on post-operative day four.", + "APGARs were 1, 6, and 8.", + "The neonatal course was complicated by prematurity.", + "The neonatal course was complicated by respiratory distress.", + "The neonatal course required a 19-day NICU stay.", + "Histology revealed an intact unremarkable placental disc loosely adherent to the posterior uterine wall.", + "Histology revealed a tan-pink, spongy cystic mass densely adherent to the right uterine wall measuring 13.5 cm by 7.7 cm by 2.6 cm.", + "Hematoxylin and eosin slides showed a complete hydatidiform mole displaying intrauterine implantation.", + "Hematoxylin and eosin slides showed focal extension of a molar villous into the superficial myometrium.", + "Hematoxylin and eosin slides showed focal extension of a molar villous into the superficial myometrium, which is diagnostic of invasive hydatidiform mole.", + "There was complete absence of immunohistochemical staining for p57 in the molar villi and hyperplastic trophoblast.", + "The complete absence of immunohistochemical staining for p57 confirmed the diagnosis of complete hydatidiform mole.", + "There is a distinct interface identified without invasion into the normal placental disc.", + "Based on her WHO score and FIGO stage 1 disease, she was low risk for recurrence or progression.", + "She was followed with serial hCGs.", + "Her hCG nadir was 8.0 before rising two months after delivery, consistent with post-molar GTN.", + "She has since finished 4 cycles of single agent Actinomycin D.", + "She received 3 cycles of chemotherapy past a negative hCG.", + "She is now 8 months from treatment with no evidence of disease by exam.", + "She is now 8 months from treatment with serially negative hCG testing." + ], + "summary": "This case looks at the diagnosis, management, and maternal-fetal outcomes of a viable fetus coexisting molar pregnancy at a large academic center in an abortion-restricted state.", + "summary_subclaims": [ + "This case looks at the diagnosis of a viable fetus coexisting molar pregnancy.", + "This case looks at the management of a viable fetus coexisting molar pregnancy.", + "This case looks at maternal-fetal outcomes of a viable fetus coexisting molar pregnancy.", + "The case is from a large academic center.", + "The case is from an abortion-restricted state." + ] + }, + { + "id": "multiclinsum_test_1176_en.txt", + "fulltext": "A 79-year-old white man presented to clinic with macroscopic hematuria for over 3 months. The patient denied a history of bladder cancer and physical examination revealed no palpable abdominal or renal masses. On multiparametric Magnetic Resonance Imaging (MRI), a lesion measuring 3.6 × 3.1 × 2.7 cm was seen in the interpolar region of the left kidney without involvement of the renal vein or collecting system . No left sided hydronephrosis or intraabdominal metastasis were appreciated. The right kidney was found to be atrophic. The patient’s medical history was significant for CKD as well as coronary artery disease (CAD) status post coronary artery bypass graft surgery (CABG). Serum creatinine was 1.3 mg./dL, Ca 9.2 mg/dL, albumin 4.2 g/dL, and hemoglobin was 13.7 g/dL. Urine culture was negative. Chest CT revealed no signs of thoracic metastasis.\nInitial workup cystoscopy was negative for a bladder mass or bloody efflux from either ureteral orifice, however prostatomegaly was noted. In addition, abdominal MRI images noted endophytic complex cystic mass with solid components making renal cell carcinoma the most likely suspected diagnosis. Considering the patient's comorbidities and the significance of preserving adequate renal function in patients with a solitary kidney, he elected for renal mass biopsy followed by immediate cryoablation as the treatment modality.\nThe patient was taken to the Interventional Radiology suite for biopsy and cryoablation of the left renal lesion. Under Computerized Tomography (CT) guidance with the patient prone, three 18-gauge core pretreatment biopsies were obtained from the renal mass. Subsequently, three ice-rod probes were distributed across the lesion to maximize treatment margins and two freeze–thaw cycles were carried out. Repeat unenhanced and contrast enhanced CT showed evidence of complete lesion ablation with satisfactory margins. The pathology of the biopsy later confirmed low-grade UTUC. Given this diagnosis was not anticipated, further discussion was warranted regarding the patient’s increased risk of recurrence due to the pathology of his disease. Retrograde ureteroscopy, biopsy, and laser fulguration three months after cryoablation was elected as the next step in management.\nUnder general anesthesia, full and thorough surveillance cystoscopy was negative for any bladder lesions and left retrograde pyelogram demonstrated no filling defects but an interpolar calyx appeared compressed . A Wolf fiber optic ureteroscope was utilized for complete pyeloscopy. Yellow-white discoloration with surrounding mucosal edema was visualized in the interpolar calyx consistent with necrotic tissue after cryoablation; however, no obvious papillary fronds of tumor were seen. A Segura four wire basket was deployed to biopsy the superficial necrotic and edematous mucosa followed by BIGopsy biopsy forceps for deep tissue samples. Holmium laser fulguration was applied for bleeding control and obliteration of any potential residual disease. The collected specimens were sent separately. Pathology results from the superficial biopsy demonstrated fragments of non-invasive low-grade papillary urothelial carcinoma. Deeper biopsies revealed cells of uncertain malignant potential in a background of extensive hyaline necrosis and fibrin deposition, corroborating scar hyperplasia and tissue transformation after cryoablation.\nThe patient was monitored over a 5 year period with annual surveillance cystoscopy, bladder cytology, and multiparametric MRI/MRU. To our satisfaction, no visible recurrence of the lesion was observed, and the patient's renal function remained stable , suggesting the success of this unconventional treatment approach to achieve favorable outcomes. The lack of disease recurrence and preservation of renal function attest to the success of cryoablation in this case.", + "fulltext_subclaims": [ + "The patient is a 79-year-old white man.", + "The patient had macroscopic hematuria for over 3 months.", + "The patient denied a history of bladder cancer.", + "Physical examination revealed no palpable abdominal or renal masses.", + "Multiparametric MRI showed a lesion measuring 3.6 × 3.1 × 2.7 cm in the interpolar region of the left kidney.", + "The lesion did not involve the renal vein or collecting system.", + "No left-sided hydronephrosis was appreciated.", + "No intraabdominal metastasis was appreciated.", + "The right kidney was found to be atrophic.", + "The patient had a history of coronary artery disease.", + "The patient had a history of coronary artery bypass graft surgery.", + "Serum creatinine was 1.3 mg/dL.", + "Chest CT revealed no signs of thoracic metastasis.", + "Initial workup cystoscopy was negative for a bladder mass.", + "Initial workup cystoscopy was negative for bloody efflux from either ureteral orifice.", + "Prostatomegaly was noted on cystoscopy.", + "Abdominal MRI images noted an endophytic complex cystic mass with solid components.", + "Renal cell carcinoma was the most likely suspected diagnosis.", + "The patient elected for renal mass biopsy followed by immediate cryoablation.", + "The patient was taken to the Interventional Radiology suite for biopsy and cryoablation.", + "Three 18-gauge core pretreatment biopsies were obtained from the renal mass.", + "Three ice-rod probes were distributed across the lesion.", + "Two freeze–thaw cycles were carried out.", + "Repeat CT showed evidence of complete lesion ablation with satisfactory margins.", + "The pathology of the biopsy later confirmed low-grade UTUC.", + "Retrograde ureteroscopy, biopsy, and laser fulguration three months after cryoablation was elected.", + "Under general anesthesia, full and thorough surveillance cystoscopy was negative for any bladder lesions.", + "A Wolf fiber optic ureteroscope was utilized for complete pyeloscopy.", + "Yellow-white discoloration with surrounding mucosal edema was visualized in the interpolar calyx.", + "A Segura four wire basket was deployed to biopsy the superficial necrotic and edematous mucosa.", + "BIGopsy biopsy forceps were used for deep tissue samples.", + "Holmium laser fulguration was applied for bleeding control.", + "The collected specimens were sent separately.", + "Pathology results from the superficial biopsy demonstrated fragments of non-invasive low-grade papillary urothelial carcinoma.", + "Deeper biopsies revealed cells of uncertain malignant potential in a background of extensive hyaline necrosis and fibrin deposition.", + "The patient was monitored over a 5 year period with annual surveillance cystoscopy.", + "The patient was monitored over a 5 year period with annual bladder cytology.", + "The patient was monitored over a 5 year period with multiparametric MRI/MRU.", + "No visible recurrence of the lesion was observed.", + "The patient's renal function remained stable.", + "The lack of disease recurrence and preservation of renal function attest to the success of cryoablation in this case." + ], + "summary": "A 79 year old male presents after three months of macroscopic hematuria. Imaging revealed a 3.6 × 3.1 × 2.7 cm endophytic mass in the interpolar region of the left kidney and an atrophic right kidney. After weighing the lesion's location with the patient's of complex medical history, he was counselled to undergo a minimally invasive percutaneous cryoablation as treatment for his solitary renal mass. A diagnostic dilemma was encountered as imaging suggested a diagnosis of renal cell carcinoma. However, the pre-ablation biopsy established an alternative diagnosis, revealing UTUC. Percutaneous cryoablation became an unorthodox treatment modality for the endophytic component of his UTUC followed by retrograde ureteroscopic laser fulguration. The patient was followed in 3 months, 6 months, then annually with cross sectional imaging by MRI, cystoscopy, urine cytology and renal function testing. After five years of follow-up, the patient did not encountered recurrence of UTUC or deterioration in renal function, thereby maintaining a stable eGFR.", + "summary_subclaims": [ + "The patient is a 79 year old male.", + "The patient had three months of macroscopic hematuria.", + "Imaging revealed a 3.6 × 3.1 × 2.7 cm endophytic mass in the interpolar region of the left kidney.", + "The right kidney was atrophic.", + "The patient was counselled to undergo a minimally invasive percutaneous cryoablation.", + "The lesion was a solitary renal mass.", + "Imaging suggested a diagnosis of renal cell carcinoma.", + "A pre-ablation biopsy established an alternative diagnosis.", + "The biopsy revealed UTUC.", + "Percutaneous cryoablation was an unorthodox treatment modality for the endophytic component of his UTUC.", + "Retrograde ureteroscopic laser fulguration was performed.", + "The patient was followed in 3 months, 6 months, then annually.", + "Follow-up included cross sectional imaging by MRI.", + "Follow-up included cystoscopy.", + "Follow-up included urine cytology.", + "Follow-up included renal function testing.", + "After five years of follow-up, the patient did not encounter recurrence of UTUC.", + "After five years of follow-up, the patient did not encounter deterioration in renal function.", + "The patient maintained a stable eGFR." + ] + }, + { + "id": "multiclinsum_test_1530_en.txt", + "fulltext": "A 61-year-old man fell from a bed in a facility, bruised his head, and lost consciousness, being brought to our hospital. The patient had a history of craniotomy for the left putaminal hemorrhage at the age of 50, which caused permanent motor aphasia and right hemiparesis (manual muscle test [MMT], 2/5). On admission, the patient was comatose associated with the left hemiplegia and was found to have a subcutaneous hematoma and abrasion on his right forehead. He had neither disorders of coagulation nor consumption of alcohol or anticoagulants. Computed tomography (CT) of the head showed AISDH of 2.5 cm in thickness and thin bilateral convexity subdural hematomas . Because he was comatose and had left hemiplegia, hematoma removal through a parietal parasagittal craniotomy was performed under the microscope. Intraoperatively, there was neither brain contusion nor a rupture of the bridging vein found . As the hematoma was removed, arterial bleeding was seen arising from a branch of ACA . The vessel was torn and the other end was found to be continuous with the cerebral falx, from which arterial bleeding was also observed . Both ends of the vessel were very close together and coagulated to stop bleeding : thus, it was determined that the damage to the dural branch from ACA to the cerebral falx was the cause of the hemorrhage. Postoperative CT demonstrated that the AISDH was near totally removed . His altered sensorium and left hemiplegia improved mildly, but the patient remained bedridden and quadriparetic. Therefore, further vascular examinations were not performed. There was no recurrent bleeding during his stay in our hospital. He was transferred to a long-term hospital with modified Rankin Scale 5 with motor aphasia and right hemiparesis (MMT, 2/5), which were sequelae that he had before the trauma, and left hemiparesis (MMT, 3/5) on the 44th postoperative day.", + "fulltext_subclaims": [ + "The patient was a 61-year-old man.", + "He fell from a bed in a facility.", + "He bruised his head.", + "He lost consciousness.", + "He had a history of craniotomy for the left putaminal hemorrhage at the age of 50.", + "The craniotomy caused permanent motor aphasia.", + "The craniotomy caused right hemiparesis (manual muscle test [MMT], 2/5).", + "On admission, the patient was comatose.", + "He had left hemiplegia.", + "Computed tomography (CT) of the head showed AISDH of 2.5 cm in thickness.", + "CT showed thin bilateral convexity subdural hematomas.", + "Hematoma removal through a parietal parasagittal craniotomy was performed under the microscope.", + "Intraoperatively, there was neither brain contusion nor a rupture of the bridging vein found.", + "Arterial bleeding was seen arising from a branch of ACA.", + "The vessel was torn.", + "The other end of the vessel was found to be continuous with the cerebral falx.", + "Both ends of the vessel were very close together and coagulated to stop bleeding.", + "It was determined that the damage to the dural branch from ACA to the cerebral falx was the cause of the hemorrhage.", + "Postoperative CT demonstrated that the AISDH was near totally removed.", + "His altered sensorium and left hemiplegia improved mildly.", + "The patient remained bedridden and quadriparetic.", + "Further vascular examinations were not performed.", + "There was no recurrent bleeding during his stay in our hospital.", + "He was transferred to a long-term hospital.", + "He had modified Rankin Scale 5.", + "He had motor aphasia.", + "He had right hemiparesis (MMT, 2/5).", + "He had left hemiparesis (MMT, 3/5)." + ], + "summary": "A 61-year-old man with a history of craniotomy for the left putaminal hemorrhage at the age of 50 fell from a bed, bruised his head, and lost consciousness. Computed tomography of the head showed AISDH of 2.5cm in thickness, which was removed through a parietal parasagittal craniotomy under the microscope. Intraoperatively, the bleeding source was revealed to be a damaged dural branch from ACA to the cerebral falx. There was no rebleeding during his stay in our hospital.", + "summary_subclaims": [ + "The patient is a 61-year-old man.", + "He has a history of craniotomy for the left putaminal hemorrhage at the age of 50.", + "He fell from a bed, bruised his head, and lost consciousness.", + "Computed tomography of the head showed AISDH of 2.5cm in thickness.", + "The AISDH was removed through a parietal parasagittal craniotomy under the microscope.", + "Intraoperatively, the bleeding source was revealed to be a damaged dural branch from ACA to the cerebral falx.", + "There was no rebleeding during his stay in our hospital." + ] + }, + { + "id": "multiclinsum_test_2779_en.txt", + "fulltext": "A 69-year-old female patient with a long vascular history and atrial flutter, presented with acute critical limb ischemia of the left extremity after stopping her anticoagulation (apixaban).\nShe had received an aortobifemoral graft at the age of 53, and had two prior episodes with acute occlusion of the right limb of the graft, 10 and 14 years after the primary operation. Both occlusions was resolved with catheter-directed thrombolysis, the last time with application of a stent in the proximal part of the right limb of the graft.\nCTA confirmed occlusion of the left leg of the aortic-bifemoral bypass, and new short occlusions of two calf arteries. There was also wall thrombus in the native aorta above the graft, as well as in the main body of the graft.\nAfter discussion with the vascular surgeon, we started catheter-based intraluminal tPA-administration via a crossover hook-shaped catheter, with the intention to aspirate residual emboli from the calf the next day if needed.\nAfter 12 h, the thrombus was dissolved. There was significant residual stenosis due to neointimal hyperplasia or wall adherent thrombus in the proximal limb, and the left groin was punctured to apply kissing stents at the bifurcation of the graft . Control angiograms after stent placement showed restricted flow through the left limb, with correct placement of the wire in the aorta above the graft anastomosis . The findings of the angiograms were consistent with neointimal dissection at two levels. At the proximal level, the stent was deployed inside the false lumen without inflow, but with the distal end inside the true lumen. The proximal neointimal dissection could only be resolved with prolonging the kissing stents all the way to the proximal graft anastomosis . The distal dissection was not flow limiting after the wire was moved to the correct lumen via buddy wire technique, and this dissection was left untreated.\nEmboli to the left calf were aspirated via a new antegrade puncture in the left groin, but completion angiograms showed some residual thrombi and a chronic occlusion of the dorsal pedal artery.\nThe patient is back to her habitual state 6 months after the procedure, with no rest pain or wounds, but claudication at 500 m. Initially after the procedure the patient received dual antiplatelet therapy, but she was reinstated on apixaban from the cardiologist due to atrial flutter at dismissal from the hospital. She is currently on life-long anticoagulation and antiplatelet therapy with apixaban and ASA.", + "fulltext_subclaims": [ + "The patient is a 69-year-old female.", + "She has a long vascular history.", + "She has atrial flutter.", + "She presented with acute critical limb ischemia of the left extremity.", + "The acute critical limb ischemia occurred after stopping her anticoagulation (apixaban).", + "She had received an aortobifemoral graft at the age of 53.", + "She had two prior episodes with acute occlusion of the right limb of the graft.", + "The first prior occlusion was 10 years after the primary operation.", + "The second prior occlusion was 14 years after the primary operation.", + "Both occlusions were resolved with catheter-directed thrombolysis.", + "The last prior occlusion was resolved with application of a stent in the proximal part of the right limb of the graft.", + "CTA confirmed occlusion of the left leg of the aortic-bifemoral bypass.", + "CTA showed new short occlusions of two calf arteries.", + "CTA showed wall thrombus in the native aorta above the graft.", + "CTA showed wall thrombus in the main body of the graft.", + "We started catheter-based intraluminal tPA-administration via a crossover hook-shaped catheter.", + "The intention was to aspirate residual emboli from the calf the next day if needed.", + "After 12 h, the thrombus was dissolved.", + "There was significant residual stenosis due to neointimal hyperplasia or wall adherent thrombus in the proximal limb.", + "The left groin was punctured to apply kissing stents at the bifurcation of the graft.", + "Control angiograms after stent placement showed restricted flow through the left limb.", + "The findings of the angiograms were consistent with neointimal dissection at two levels.", + "At the proximal level, the stent was deployed inside the false lumen without inflow.", + "The distal end of the stent was inside the true lumen.", + "The proximal neointimal dissection could only be resolved with prolonging the kissing stents all the way to the proximal graft anastomosis.", + "The distal dissection was not flow limiting after the wire was moved to the correct lumen via buddy wire technique.", + "The distal dissection was left untreated.", + "Emboli to the left calf were aspirated via a new antegrade puncture in the left groin.", + "Completion angiograms showed some residual thrombi.", + "Completion angiograms showed a chronic occlusion of the dorsal pedal artery.", + "The patient is back to her habitual state 6 months after the procedure.", + "She has no rest pain or wounds.", + "She has claudication at 500 m.", + "Initially after the procedure, the patient received dual antiplatelet therapy.", + "She was reinstated on apixaban from the cardiologist due to atrial flutter at dismissal from the hospital.", + "She is currently on life-long anticoagulation and antiplatelet therapy with apixaban and ASA." + ], + "summary": "We present here a case of a 69-year-old female with acute occlusion of the limb of an aorto-bifemoral graft for the third time, 16 years after the primary operation. As at the first two occasions, catheter-based intra-arterial thrombolysis was performed, but with residual stenosis inside the graft. During stent placement, dissection of the neointima or fibrin sheet occluded the inflow to the stent. The complication was resolved with placement of kissing stents.", + "summary_subclaims": [ + "The patient is a 69-year-old female.", + "The patient had acute occlusion of the limb of an aorto-bifemoral graft for the third time.", + "The occlusion occurred 16 years after the primary operation.", + "Catheter-based intra-arterial thrombolysis was performed.", + "There was residual stenosis inside the graft.", + "During stent placement, dissection of the neointima or fibrin sheet occluded the inflow to the stent.", + "The complication was resolved with placement of kissing stents." + ] + }, + { + "id": "multiclinsum_test_256_en.txt", + "fulltext": "A 65 year-old white male began symptoms of weakness for medium efforts in March 2007. Two months later, during one week, he had 2 episodes of dark feces, associated with periumbilical pain, irradiating to the flancs and epigastric area. He denied heart burn, pyrosis, regurgitation, post-prandial fullness, nausea, vomiting, diarrhea and loss of apetite. Blood tests revealed normocytic normochromic anemia (hemoglobin = 11.1 g/dL), and upper gastrointestinal endoscopy was normal. During the next two months there was aggravation of anemia (hemoglobin = 7.2 g/dL, mean globular volume = 67.6 fL) and progressive asthenia, without evident blood loss or gastrointestinal symptoms, coming then to the Emergency Room. The patient had a past history of chronic hepatitis B, arterial hypertension, gout, dislipidemia and had removed colo-rectal polyps, with an unknown histologic diagnosis, 3 years before. He presented an alcohol consumption of 75 g of ethanol / day, was a former smoker (10 pack years), and was medicated with losartan+hydrochlorothiazide, allopurinol and simvastatin+ezetimibe. In the past 18 months the patient referred a weight loss of 15 kg.\nPhysical observation, apart from descoloration of skin and mucous membranes, was unremarkable, revealing no palpable adenomegaly (including absence of Virchow node), no abdominal masses, and a normal digital rectal examination. Blood tests confirmed a blood loss / iron-deficiency anemia (serum iron = 4μg/dL, serum ferritin = 8.1 ng/dL, percent transferrin saturation = 1.06%, total iron-binding capacity = 313 mg/dL), but were otherwise normal. Chest x-Ray showed cardiomegaly and clear lungs. The upper gastroduodenal endoscopy revealed no lesions. Colonoscopy identified 3 polyps, with no signs of bleeding, in the sigmoid, descendent colon and cecum, corresponding to tubular adenomas with low-grade dysplasia which did not seem to be responsible for the clinical presentation. Since we were unable to proceed with capsule endoscopy due to difficult availability in our hospital, we decided to do an abdominal CT-scan, which showed a diffuse upper jejunal thickening with local, retrocural and peri-aortic adenomegaly, along with distension of D3 suggesting a suboclusive pattern . The day after the CT scan, the patient began with retching, so programmed surgery was antecipated. Resection of upper jejunum and regional lymph nodes, with jejuno-duodenal anastomosis, was performed. The histologic examination revealed an ulcerated, poorly diferentiated adenocarcinoma - T4N2M0 (stage III) ( and ).\nSix months after surgery, follow-up CT scan revealed evidence of local recurrence of the tumour, again with lymph node involvement. The patient was proposed for chemotherapy with six cycles of capecitabine. By the end of the second cycle the patient started vomiting and abdominal pain relieved by metochlopramide and diazepam, allowing the third cycle. Due to recurrence of symptoms and marked weight loss he then repeated the CT scan, once more revealing diffuse upper jejunal thickening with distension of D3, extensive lymph node dissemination (abdomen and thorax), and a single hepatic metastasis at segment IV. A paliative bypass was performed with successful symptomatic relieve and the patient is still alive 14 months after diagnosis.", + "fulltext_subclaims": [ + "The patient is a 65 year-old white male.", + "He began symptoms of weakness for medium efforts in March 2007.", + "Two months later, during one week, he had 2 episodes of dark feces.", + "The dark feces were associated with periumbilical pain irradiating to the flanks and epigastric area.", + "He denied heart burn.", + "He denied pyrosis.", + "He denied regurgitation.", + "He denied post-prandial fullness.", + "He denied nausea.", + "He denied vomiting.", + "He denied diarrhea.", + "He denied loss of appetite.", + "Blood tests revealed normocytic normochromic anemia with hemoglobin = 11.1 g/dL.", + "Upper gastrointestinal endoscopy was normal.", + "During the next two months there was aggravation of anemia with hemoglobin = 7.2 g/dL.", + "During the next two months there was aggravation of anemia with mean globular volume = 67.6 fL.", + "The patient had a past history of chronic hepatitis B.", + "The patient had a past history of arterial hypertension.", + "The patient had a past history of gout.", + "The patient had a past history of dyslipidemia.", + "The patient had removed colo-rectal polyps 3 years before.", + "The colo-rectal polyps had an unknown histologic diagnosis.", + "The patient had an alcohol consumption of 75 g of ethanol / day.", + "The patient was a former smoker with 10 pack years.", + "The patient was medicated with losartan+hydrochlorothiazide.", + "The patient was medicated with allopurinol.", + "The patient was medicated with simvastatin+ezetimibe.", + "In the past 18 months the patient referred a weight loss of 15 kg.", + "Physical observation revealed descoloration of skin and mucous membranes.", + "Physical observation revealed no palpable adenomegaly, including absence of Virchow node.", + "Physical observation revealed no abdominal masses.", + "Physical observation revealed a normal digital rectal examination.", + "Blood tests confirmed a blood loss / iron-deficiency anemia with serum iron = 4μg/dL.", + "Blood tests confirmed a blood loss / iron-deficiency anemia with serum ferritin = 8.1 ng/dL.", + "Blood tests confirmed a blood loss / iron-deficiency anemia with percent transferrin saturation = 1.06%.", + "Blood tests confirmed a blood loss / iron-deficiency anemia with total iron-binding capacity = 313 mg/dL.", + "Chest x-Ray showed cardiomegaly.", + "Chest x-Ray showed clear lungs.", + "Upper gastroduodenal endoscopy revealed no lesions.", + "Colonoscopy identified 3 polyps in the sigmoid, descending colon and cecum.", + "The colonoscopic polyps corresponded to tubular adenomas with low-grade dysplasia.", + "The colonoscopic polyps did not seem to be responsible for the clinical presentation.", + "An abdominal CT-scan showed a diffuse upper jejunal thickening.", + "An abdominal CT-scan showed local, retrocural and peri-aortic adenomegaly.", + "An abdominal CT-scan showed distension of D3 suggesting a suboclusive pattern.", + "The day after the CT scan, the patient began with retching.", + "Resection of upper jejunum and regional lymph nodes was performed.", + "Jejuno-duodenal anastomosis was performed.", + "The histologic examination revealed an ulcerated, poorly differentiated adenocarcinoma.", + "The histologic examination revealed T4N2M0 (stage III).", + "Six months after surgery, follow-up CT scan revealed evidence of local recurrence of the tumour.", + "Follow-up CT scan revealed again lymph node involvement.", + "The patient was proposed for chemotherapy with six cycles of capecitabine.", + "By the end of the second cycle the patient started vomiting.", + "By the end of the second cycle the patient had abdominal pain relieved by metoclopramide and diazepam.", + "Due to recurrence of symptoms and marked weight loss, the patient repeated the CT scan.", + "The repeated CT scan revealed diffuse upper jejunal thickening.", + "The repeated CT scan revealed distension of D3.", + "The repeated CT scan revealed extensive lymph node dissemination (abdomen and thorax).", + "The repeated CT scan revealed a single hepatic metastasis at segment IV.", + "A palliative bypass was performed.", + "The palliative bypass provided successful symptomatic relief.", + "The patient is still alive 14 months after diagnosis." + ], + "summary": "We report a case of jejunal adenocarcinoma presenting as a blood loss anemia in a 65 year-old male, doing a brief review on the subject.", + "summary_subclaims": [ + "The patient is a 65 year-old male.", + "The patient had blood loss anemia.", + "The patient had jejunal adenocarcinoma." + ] + }, + { + "id": "multiclinsum_test_3337_en.txt", + "fulltext": "The patient was a 78-year-old male smoker (half-pack per day for 50 years) who presented with progressive cough, dyspnea, and hemoptysis. Computed tomography (CT) and whole-body positron emission tomography (PET) imaging revealed 4.6 × 4.8 cm right lower lobe (RLL) and 4.8 × 2.7 cm left lower lobe (LLL) spiculated masses with increased avidity. Axillary and mediastinal lymph nodes, including subcarinal nodes, were normal in size and avidity. CT-guided percutaneous core needle biopsy of the RLL mass was performed. Histopathological examination revealed an invasive adenocarcinoma composed of acini lined with tall columnar epithelium with focal cribiforming and luminal necrosis. These cells were strongly reactive with CK-20 and CDX-2, moderately reactive with CK-7, and nonreactive with thyroid transcription factor (TTF)-1/napsin-A, which was concerning for gastrointestinal metastasis. Further evaluation with esophagogastroduodenoscopy, colonoscopy, and whole-body PET was unrevealing for gastrointestinal primary. Special AT-rich sequence-binding protein 2 (SATB2) staining of the RLL mass was also nonreactive.\n\nEndobronchial ultrasound (EBUS) was subsequently performed to complete mediastinal staging, which demonstrated a concerning level 7 subcarinal lymph node that had previously been undetected on CT/PET imaging. Transbronchial needle aspiration was performed on the LLL mass and the level 7 lymph node. Histopathological examination of both specimens revealed neoplastic cells with abundant cytoplasm and large hyperchromatic nuclei with prominent nucleoli. In contrast to the RLL, these cells were immunoreactive to TTF-1/napsin-A, and nonreactive to p40 and p63 antibodies, indicating a primary conventional lung adenocarcinoma. Next-generation sequencing (NGS) also revealed discordant profiles. The RLL mass had an intermediate tumor mutational burden (19 mutations/Mb), programmed death ligand-1 (PD-L1) tumor proportion score of 0%, KRAS wild type, and mutations in CDKN2A, NOTCH1, and TP53. NGS of the LLL adenocarcinoma demonstrated EGFR amplification, an intermediate tumor mutational burden (11 mutations/Mb), loss of CDKN2A/B, and mutations in RBM10 and TP53.\n\nAfter completion of mediastinal staging, the patient was diagnosed with pulmonary enteric adenocarcinoma of the right lobe (T2bN0M0) and conventional adenocarcinoma of the left lobe (T2bN2M0). He received palliative intent chemoimmunotherapy with carboplatin, pemetrexed, and pembrolizumab leading to complete response of the RLL PEAC and a partial response of the LLL adenocarcinoma at 6 months post-diagnosis.", + "fulltext_subclaims": [ + "The patient was a 78-year-old male smoker.", + "He smoked half a pack per day for 50 years.", + "He presented with progressive cough.", + "He presented with dyspnea.", + "He presented with hemoptysis.", + "Computed tomography (CT) and whole-body positron emission tomography (PET) imaging revealed 4.6 × 4.8 cm right lower lobe (RLL) and 4.8 × 2.7 cm left lower lobe (LLL) spiculated masses with increased avidity.", + "Axillary and mediastinal lymph nodes, including subcarinal nodes, were normal in size and avidity.", + "CT-guided percutaneous core needle biopsy of the RLL mass was performed.", + "Histopathological examination revealed an invasive adenocarcinoma composed of acini lined with tall columnar epithelium with focal cribiforming and luminal necrosis.", + "These cells were strongly reactive with CK-20.", + "These cells were strongly reactive with CDX-2.", + "These cells were moderately reactive with CK-7.", + "These cells were nonreactive with thyroid transcription factor (TTF)-1/napsin-A.", + "Further evaluation with esophagogastroduodenoscopy, colonoscopy, and whole-body PET was unrevealing for gastrointestinal primary.", + "Special AT-rich sequence-binding protein 2 (SATB2) staining of the RLL mass was also nonreactive.", + "Endobronchial ultrasound (EBUS) was subsequently performed to complete mediastinal staging.", + "EBUS demonstrated a concerning level 7 subcarinal lymph node that had previously been undetected on CT/PET imaging.", + "Transbronchial needle aspiration was performed on the LLL mass.", + "Transbronchial needle aspiration was performed on the level 7 lymph node.", + "Histopathological examination of both specimens revealed neoplastic cells with abundant cytoplasm and large hyperchromatic nuclei with prominent nucleoli.", + "These cells were immunoreactive to TTF-1/napsin-A.", + "These cells were nonreactive to p40 and p63 antibodies.", + "Next-generation sequencing (NGS) also revealed discordant profiles.", + "The RLL mass had an intermediate tumor mutational burden (19 mutations/Mb).", + "The RLL mass had a programmed death ligand-1 (PD-L1) tumor proportion score of 0%.", + "The RLL mass had KRAS wild type.", + "The RLL mass had mutations in CDKN2A, NOTCH1, and TP53.", + "The LLL adenocarcinoma demonstrated EGFR amplification.", + "The LLL adenocarcinoma had an intermediate tumor mutational burden (11 mutations/Mb).", + "The LLL adenocarcinoma had loss of CDKN2A/B.", + "The LLL adenocarcinoma had mutations in RBM10 and TP53.", + "After completion of mediastinal staging, the patient was diagnosed with pulmonary enteric adenocarcinoma of the right lobe (T2bN0M0).", + "After completion of mediastinal staging, the patient was diagnosed with conventional adenocarcinoma of the left lobe (T2bN2M0).", + "He received palliative intent chemoimmunotherapy with carboplatin, pemetrexed, and pembrolizumab.", + "He had a complete response of the RLL PEAC at 6 months post-diagnosis.", + "He had a partial response of the LLL adenocarcinoma at 6 months post-diagnosis." + ], + "summary": "We report the case of a 78-year-old man with synchronously diagnosed locally advanced pulmonary adenocarcinoma of the left lower lobe and localized right lower lobe PEAC. These malignancies exhibited distinct tumor molecular profiles and differed in their kinetic response to chemoimmunotherapy. We describe plausible mechanisms by which two distinct pulmonary malignancies are present in the contralateral lobes.", + "summary_subclaims": [ + "The patient was a 78-year-old man.", + "The patient had synchronously diagnosed locally advanced pulmonary adenocarcinoma of the left lower lobe.", + "The patient had localized right lower lobe PEAC.", + "The malignancies exhibited distinct tumor molecular profiles.", + "The malignancies differed in their kinetic response to chemoimmunotherapy.", + "Plausible mechanisms are described by which two distinct pulmonary malignancies are present in the contralateral lobes." + ] + }, + { + "id": "multiclinsum_test_553_en.txt", + "fulltext": "This 77-year-old man with a medical history including coronary artery disease and dysrhythmia presented to the neurosurgery clinic after months of evaluations for repeated episodes of presyncope and at least four syncopal events, where the patient was found unconscious or had awoken on the ground after presumably losing consciousness. The patient reported these symptoms and events were preceded by turning his head to the right. In some instances, the patient reported double vision in conjunction with the presyncopal symptoms.\nOn physical examination, the patient was neurologically intact. He was able to reproduce the symptoms with head rotation of approximately 45° to the right. As a matter of safety, these assessments were performed in short intervals as to not elicit a full syncopal event. Diplopia was not detected. A CT angiogram (CTa) of the head and neck demonstrated osseous changes consistent with cervical DISH as well as a “fang”-like osseous elongation of the right C5 lateral mass, which protruded into the vertebral foramen and compressed the VA . A catheter-based cranial and cervical digital subtraction angiogram (DSA) demonstrated approximately 74% stenosis of the right VA at C5 in the neutral position, which progressed to full occlusion with right head rotation . In addition, the patient was found to have a left VA which ended in an ipsilateral posterior inferior cerebellar artery without joining the right VA.\nA C4–5 anterior cervical discectomy and fusion (ACDF) was performed under general endotracheal anesthesia. The traditional Smith-Robinson approach to the cervical spine was employed and special care was taken not to injure the esophagus, which had been displaced to the right of the cervical spine by large hyperostotic osteophytes. In addition to the C4–5 discectomy, partial osteophyte removal was required at C5 to allow for the plating system to lay flat. A structural allograft and low-profile titanium plating system was used to complete the surgery.\nThe patient tolerated surgery well and was discharged on postoperative day 1. He had an uneventful recovery and reported complete resolution of his symptoms with head rotation. Approximately 9 months after surgery, the patient underwent a repeat CTa and DSA as part of an evaluation for cardiac dysrhythmia. The CTa demonstrated blunting of the osseous growth at C5, and the DSA showed no evidence of VA compression in the neutral or dynamic positions .", + "fulltext_subclaims": [ + "The patient is a 77-year-old man.", + "The patient has a medical history including coronary artery disease.", + "The patient has a medical history including dysrhythmia.", + "The patient had repeated episodes of presyncope.", + "The patient had at least four syncopal events.", + "The patient reported these symptoms and events were preceded by turning his head to the right.", + "In some instances, the patient reported double vision in conjunction with the presyncopal symptoms.", + "On physical examination, the patient was neurologically intact.", + "The patient was able to reproduce the symptoms with head rotation of approximately 45° to the right.", + "These assessments were performed in short intervals as to not elicit a full syncopal event.", + "Diplopia was not detected.", + "A CT angiogram of the head and neck demonstrated osseous changes consistent with cervical DISH.", + "A CT angiogram demonstrated a 'fang'-like osseous elongation of the right C5 lateral mass.", + "The 'fang'-like osseous elongation protruded into the vertebral foramen.", + "The 'fang'-like osseous elongation compressed the VA.", + "A catheter-based cranial and cervical digital subtraction angiogram demonstrated approximately 74% stenosis of the right VA at C5 in the neutral position.", + "The stenosis progressed to full occlusion with right head rotation.", + "The patient was found to have a left VA which ended in an ipsilateral posterior inferior cerebellar artery without joining the right VA.", + "A C4–5 anterior cervical discectomy and fusion was performed under general endotracheal anesthesia.", + "The traditional Smith-Robinson approach to the cervical spine was employed.", + "Special care was taken not to injure the esophagus, which had been displaced to the right of the cervical spine by large hyperostotic osteophytes.", + "Partial osteophyte removal was required at C5 to allow for the plating system to lay flat.", + "A structural allograft and low-profile titanium plating system was used to complete the surgery.", + "The patient tolerated surgery well.", + "The patient was discharged on postoperative day 1.", + "The patient reported complete resolution of his symptoms with head rotation.", + "Approximately 9 months after surgery, the patient underwent a repeat CT angiogram and digital subtraction angiogram.", + "The CT angiogram demonstrated blunting of the osseous growth at C5.", + "The digital subtraction angiogram showed no evidence of VA compression in the neutral or dynamic positions." + ], + "summary": "A 77-year-old man who presented with BHS was found to have cervical spine changes consistent with DISH, and angiography confirmed right vertebral artery (VA) stenosis at C4-5 from a large pathological elongation of the right C5 lateral mass. Head rotation resulted in occlusion of the VA. The patient underwent an anterior cervical discectomy and fusion and reported complete resolution of his symptoms. A delayed angiogram and CT of the cervical spine demonstrated complete resolution of the baseline stenosis, no dynamic compression, and remote osseous remodeling of the growth, respectively.", + "summary_subclaims": [ + "The patient is a 77-year-old man.", + "The patient presented with BHS.", + "Cervical spine changes were consistent with DISH.", + "Angiography confirmed right vertebral artery stenosis at C4-5.", + "The stenosis was from a large pathological elongation of the right C5 lateral mass.", + "Head rotation resulted in occlusion of the VA.", + "The patient underwent an anterior cervical discectomy and fusion.", + "The patient reported complete resolution of his symptoms.", + "A delayed angiogram demonstrated complete resolution of the baseline stenosis.", + "A delayed CT of the cervical spine showed remote osseous remodeling of the growth." + ] + }, + { + "id": "multiclinsum_test_2763_en.txt", + "fulltext": "A 38-year-old white Arabian woman, gravida 1, parity 0, abort 1, sought medical advice in our outpatient clinic with complaints of lower abdominal pain that had started 2 days earlier. The pain had first started as mild cramps, which then suddenly intensified nearly 2 hours before her presentation to our clinic, spread to her groin and femur, more prominent on the right side, and became an ongoing pain. The patient had not had any complaints of pain until 2 days earlier in her anamnesis, and she stated that her nausea had started together with the intensification of pain, but she had not vomited. In her medical history, the patient stated that a doctor she had sought medical advice from for infertility about 3 years ago had recommended bilateral salpingectomy and in vitro fertilization treatment due to hydrosalpinx, but the patient did not undergo these procedures. She had undergone no previous abdominal operation. In the patient’s physical evaluation, we measured TA 110/70 mmHg, pulse rate 95 beats/minute, and no fever. The patient’s abdominal examination revealed significant defenses and rebounds in the lower abdominal quadrants, and significant sensitivity was detected in the upper and middle quadrants. Cervical movements were painful during the gynecologic examination. Transvaginal and abdominal ultrasonographic (US) examinations revealed that the uterus was normal, both ovaries were separated and normal, and two irregular cystic masses of 35 mm and 40 mm (possibly hydrosalpinx) were observed in the region close to the left adnexal lobe, and minimal free fluid was seen in the pouch of Douglas. Laboratory test findings were as follows: white blood cell count 9.46 × 103/mm3, hemoglobin 9.3 g/dl, hematocrit 28.67%, and β-human chorionic gonadotropin (β-hCG) detected as negative. Tumor marker values were within normal limits (CA 125, 8.6 U/ml; CA 15-3, 12.08 U/ml; CA 19-9, 9.73 U/ml; carcinoembryonic antigen, 1.57 ng/ml). A decision was made to perform emergency surgery because acute abdominal findings were apparent, with the patient describing severe pain, clinical findings progressing, and adnexal pathology being detected by US. As preoperative diagnoses of the patient, ovarian cyst rupture and ectopic pregnancy were suspected, and fallopian tube torsion was also suspected due to the normal appearance of the ovaries and the appearance of hydrosalpinx by US. The diagnosis of ectopic pregnancy was excluded because of the negative β-hCG finding. The patient underwent laparotomy with a Pfannenstiel incision. The uterus and both ovaries were normal in abdominal observation. Hydrosalpinx was found in the right tube, and it was torsioned around itself four times and necrotic . In the left tube, hydrosalpinx and 1.5 times torsion around itself were observed. The left tube was torsioned exactly at the junction of the distal hydrosalpinx and the normal proximal tubal region. There was no apparent necrotic appearance in the left tube, possibly due to the fact that circulatory disruption was not complete . Both tubes had hydrosalpinx, and the fimbrial ends were blunt and obliterated. Bilateral salpingectomy was performed on the patient because the right tube had a prominent necrotic appearance, and there was a significant hydrosalpinx in both tubes. The patient was discharged on the second postoperative day without any complaints and without any complications. Histopathological examination revealed bilateral hydrosalpinx with hemorrhagic infarction findings consistent with torsion.", + "fulltext_subclaims": [ + "The patient is a 38-year-old white Arabian woman.", + "She is gravida 1, parity 0, abort 1.", + "She sought medical advice in the outpatient clinic with complaints of lower abdominal pain that had started 2 days earlier.", + "The pain had first started as mild cramps.", + "The pain suddenly intensified nearly 2 hours before her presentation.", + "The pain spread to her groin and femur.", + "The pain was more prominent on the right side.", + "The pain became an ongoing pain.", + "The patient had not had any complaints of pain until 2 days earlier.", + "Nausea had started together with the intensification of pain.", + "She had not vomited.", + "In her medical history, a doctor had recommended bilateral salpingectomy and in vitro fertilization treatment due to hydrosalpinx.", + "The patient did not undergo these procedures.", + "She had undergone no previous abdominal operation.", + "TA was 110/70 mmHg.", + "Pulse rate was 95 beats/minute.", + "There was no fever.", + "Abdominal examination revealed significant defenses and rebounds in the lower abdominal quadrants.", + "Significant sensitivity was detected in the upper and middle quadrants.", + "Cervical movements were painful during the gynecologic examination.", + "Transvaginal and abdominal ultrasonographic examinations revealed two irregular cystic masses of 35 mm and 40 mm in the region close to the left adnexal lobe.", + "The masses were possibly hydrosalpinx.", + "Minimal free fluid was seen in the pouch of Douglas.", + "β-human chorionic gonadotropin was detected as negative.", + "Tumor marker values were within normal limits.", + "A decision was made to perform emergency surgery.", + "Preoperative diagnoses included ovarian cyst rupture and ectopic pregnancy.", + "Fallopian tube torsion was also suspected.", + "The diagnosis of ectopic pregnancy was excluded because of the negative β-hCG finding.", + "The patient underwent laparotomy with a Pfannenstiel incision.", + "Hydrosalpinx was found in the right tube.", + "The right tube was torsioned around itself four times and necrotic.", + "In the left tube, hydrosalpinx and 1.5 times torsion around itself were observed.", + "The left tube was torsioned exactly at the junction of the distal hydrosalpinx and the normal proximal tubal region.", + "There was no apparent necrotic appearance in the left tube.", + "Bilateral salpingectomy was performed on the patient.", + "The patient was discharged on the second postoperative day without any complaints and without any complications.", + "Histopathological examination revealed bilateral hydrosalpinx with hemorrhagic infarction findings consistent with torsion." + ], + "summary": "A 38-year-old white Arabian woman, gravida 1, parity 0, abort 1, sought medical advice in our outpatient clinic with a complaint of lower abdominal pain that had started 2 days earlier. The pain had first started as mild cramps, which then suddenly intensified nearly 2 hours before her presentation to our clinic, spread to the groin and femur, more prominent on the right side, and became an ongoing pain. As preoperative diagnoses of the patient, ovarian cyst rupture and ectopic pregnancy were suspected, and fallopian tube torsion was also suspected due to the normal appearance of the ovaries and the appearance of the hydrosalpinx on ultrasonography. The patient underwent laparotomy with a Pfannenstiel incision. Both tubes had hydrosalpinx, and the fimbrial ends were blunt and obliterated. Bilateral salpingectomy was performed because the right tube had a prominent necrotic appearance, and there was a significant hydrosalpinx in both tubes.", + "summary_subclaims": [ + "The patient is a 38-year-old white Arabian woman.", + "She is gravida 1, parity 0, abort 1.", + "She presented with lower abdominal pain that started 2 days earlier.", + "The pain began as mild cramps and then suddenly intensified 2 hours before presentation.", + "The pain spread to the groin and femur and was more prominent on the right side.", + "Ovarian cyst rupture and ectopic pregnancy were suspected as preoperative diagnoses.", + "Fallopian tube torsion was also suspected.", + "The patient underwent laparotomy with a Pfannenstiel incision.", + "Both tubes had hydrosalpinx.", + "The fimbrial ends were blunt and obliterated.", + "Bilateral salpingectomy was performed.", + "The right tube had a prominent necrotic appearance.", + "There was significant hydrosalpinx in both tubes." + ] + }, + { + "id": "multiclinsum_test_3076_en.txt", + "fulltext": "Female, 35 years old, with a history of asthma and alopecia areata. She presented with paresthesia of the lower limbs that progressed gradually. After one month she presented with a picture of asthenia and bifrontal headaches of moderate intensity with a poor response to analgesics and blurred vision, later with constipation and urinary incontinence. She presented with transient episodes of confusion and disorientation, with subsequent complete recovery. After three months of evolution of the clinical picture, she was admitted to a hospital in Spain for study. Complementary examinations were performed; routine laboratory, acute phase reactants (VSG, PCR), B12 and folic acid, HIV, HBV, HCV and tumour markers (CEA, CA15.3, CA125, CA19.9) were found within normal parameters. Electroforetic proteinogram without monoclonal component. Anti-GFAP antibodies in serum and CSF negative. ANAANCA, AQP4 and MOG, LGI1, NMDAR, GABAa, GABAb, GAD, Yo, Hu, Ri, Ma2, CV2, fisina, SOX1, recoverina, negative titers. Anti-GFAP antibodies in serum negative. Anti-thyroglobulin 181 (positive at low titre). Collagenogram: FAN positive 1/320, homogenous nuclear pattern. CSF: GB 53 (99% MN), glucoraquia 59 mg/dl, proteinorraquia 135 mg/dl. ADA 10.5. Cultures in CSF negative for bacteria, viruses and fungi. Oligoclonal bands type IV. Immune phenotypic cytometry, normal lymphocytes. Cytology with lymphocytes without atypia in 2 opportunities. Fundus of eye with blurring of papillae bilateral, cellular vitreous, macula normal without choroid retinitis or macular retinitis. Optical coherence tomography (OCT) with intra-retinal oedema in papillomacular bundle and bilateral papilla oedema. Study of nerve conduction: polyneuropathy sensory axonal, symmetric, with involvement of lower limbs and without denervation. Brain MRI: diffuse hyperintense lesions in T2/Flair subcortical parietal occipital, without effect of mass, without diffusion restriction. In the T1 sequence with contrast it presents captation in subcortical pattern with tendency to form a radiated and linear perivascular pattern. MRI of cervical column: oedema hyperintense in T2/Flair longitudinally extensive from bulb to dorsal spinal cord, in disposition of the centromedular. In the contrasted sequence it presents a similar pattern to the one described at the supratentorial level, with the thyroid gland and dorsal spinal column showing a pattern of leptomeningeal and parenchymal captation. Optical emission tomography of the whole body: brain with greater relative fixation of fluorodeoxyglucose (FDG) of both striata in the mesial temporal region and bilateral uncus. Diffuse hypometabolism of most of the cerebral cortex. FDG captation in thyroid gland and thyroid nodule. The study of the thyroid nodule was deepened with a diagnosis of left papillary and right follicular thyroid carcinoma (BRAAF 1). Total thyroidectomy with vaciamiento ganglionar and subsequent treatment with radioactive iodine was performed. In the face of the suspicion of inflammatory disease without precise etiology, it was decided to initiate corticoids with partial improvement of the clinical picture. After 6 months the patient was referred to our center in CABA, Argentina. On physical examination she presented preserved higher mental functions, visual acuity near and far 10/10, visual fields preserved, chromatic vision preserved, reactive isocortical pupils, extrinsic ocular movements without alterations, multidirectional nystagmus not depletable. Low pairs preserved. No neck stiffness, Kendall 5/5 in all muscle groups, hyperreflexia in upper limbs and live reflexes in lower limbs. Hoffman negative, bilateral clonus, bilateral reflexes indifferent, isocortical pupils, no nystagmus, chromatic vision preserved, isocortical pupils, no nystagmus, chromatic vision preserved, isocortical pupils, no nystagmus, isocortical pupils, no neck stiffness, Kendall 5/5 in all muscle groups, hyperreflexia in upper limbs and live reflexes in lower limbs. Isocortical pupils, no nystagmus, chromatic vision preserved, isocortical pupils, no nystagmus, isocortical pupils, no neck stiffness, Kendall 5/5 in all muscle groups, hyperreflexia in upper limbs and live reflexes in lower limbs. Isometria of D lower limbs. Romberg positive. Taconeante gait, with increased base of support. During her hospitalisation new complementary examinations were performed. Schirmer negative, ophthalmological evaluation with computerised visual field and OCT within normal parameters, serologies for Whipple negative, neuroconduction that confirmed the previously described findings. In the face of clinical and imaging suspicion, a dose of anti-GFAP antibodies in CSF was performed with a positive result, titre 1:100 and a diagnosis of astheno-myelopathy with autoimmune glial acid fibrillar protein was made. The patient continues follow-up in our centre without new clinical or imaging relapses, which is why a waiting policy was decided for the treatment according to evolution.\n", + "fulltext_subclaims": [ + "The patient is a 35-year-old woman.", + "She has a history of asthma.", + "She has a history of alopecia areata.", + "She presented with paresthesia of the lower limbs that progressed gradually.", + "After one month, she presented with asthenia.", + "After one month, she presented with bifrontal headaches of moderate intensity.", + "The headaches had a poor response to analgesics.", + "She had blurred vision.", + "She later had constipation.", + "She later had urinary incontinence.", + "She had transient episodes of confusion and disorientation.", + "The episodes of confusion and disorientation were followed by complete recovery.", + "After three months of evolution of the clinical picture, she was admitted to a hospital in Spain.", + "Routine laboratory tests were within normal parameters.", + "Acute phase reactants (VSG, PCR) were within normal parameters.", + "B12 and folic acid levels were within normal parameters.", + "HIV, HBV, HCV, and tumour markers (CEA, CA15.3, CA125, CA19.9) were within normal parameters.", + "Electroforetic proteinogram showed no monoclonal component.", + "Anti-GFAP antibodies in serum and CSF were negative.", + "ANAANCA, AQP4, MOG, LGI1, NMDAR, GABAa, GABAb, GAD, Yo, Hu, Ri, Ma2, CV2, fisina, SOX1, recoverina had negative titers.", + "Anti-GFAP antibodies in serum were negative.", + "Anti-thyroglobulin was 181 (positive at low titre).", + "Collagenogram showed FAN positive 1/320 with a homogeneous nuclear pattern.", + "CSF showed 53 GB (99% MN).", + "CSF glucose was 59 mg/dl.", + "CSF protein was 135 mg/dl.", + "CSF ADA was 10.5.", + "CSF cultures were negative for bacteria, viruses, and fungi.", + "CSF showed oligoclonal bands type IV.", + "Immune phenotypic cytometry showed normal lymphocytes.", + "Cytology showed lymphocytes without atypia in two opportunities.", + "Fundus of eye showed blurring of papillae bilaterally.", + "Fundus of eye showed cellular vitreous.", + "Fundus of eye showed a normal macula without choroid retinitis or macular retinitis.", + "OCT showed intra-retinal oedema in the papillomacular bundle.", + "OCT showed bilateral papilla oedema.", + "Nerve conduction study showed polyneuropathy sensory axonal, symmetric, with involvement of lower limbs and without denervation.", + "Brain MRI showed diffuse hyperintense lesions in T2/Flair subcortical parietal occipital.", + "Brain MRI showed no mass effect.", + "Brain MRI showed no diffusion restriction.", + "Brain MRI showed subcortical pattern captation in T1 sequence with contrast.", + "Brain MRI showed a radiated and linear perivascular pattern.", + "Cervical column MRI showed hyperintense oedema in T2/Flair longitudinally extensive from bulb to dorsal spinal cord.", + "Cervical column MRI showed a centromedullary disposition.", + "Cervical column MRI showed a similar pattern to the one described at the supratentorial level.", + "Optical emission tomography showed greater relative fixation of FDG in both striata.", + "Optical emission tomography showed greater relative fixation of FDG in the mesial temporal region.", + "Optical emission tomography showed greater relative fixation of FDG in bilateral uncus.", + "Optical emission tomography showed diffuse hypometabolism of most of the cerebral cortex.", + "Optical emission tomography showed FDG captation in the thyroid gland.", + "Optical emission tomography showed FDG captation in a thyroid nodule.", + "The thyroid nodule was diagnosed as left papillary and right follicular thyroid carcinoma.", + "The thyroid nodule had a BRAAF 1 mutation.", + "Total thyroidectomy with vaciamiento ganglionar was performed.", + "Subsequent treatment with radioactive iodine was performed.", + "Corticoids were initiated with partial improvement of the clinical picture.", + "After 6 months, the patient was referred to our center in CABA, Argentina.", + "On physical examination, higher mental functions were preserved.", + "Visual acuity near and far was 10/10.", + "Visual fields were preserved.", + "Chromatic vision was preserved.", + "Pupils were reactive and isocortical.", + "Extrinsic ocular movements were without alterations.", + "Multidirectional nystagmus was not depletable.", + "Low pairs were preserved.", + "No neck stiffness was present.", + "Kendall 5/5 was present in all muscle groups.", + "Hyperreflexia was present in upper limbs.", + "Live reflexes were present in lower limbs.", + "Hoffman sign was negative.", + "Bilateral clonus was present.", + "Bilateral reflexes were indifferent.", + "Isocortical pupils were present.", + "No nystagmus was present.", + "Chromatic vision was preserved.", + "No neck stiffness was present.", + "Kendall 5/5 was present in all muscle groups.", + "Hyperreflexia was present in upper limbs.", + "Live reflexes were present in lower limbs.", + "Isometria of D lower limbs was present.", + "Romberg test was positive.", + "Taconeante gait with increased base of support was present.", + "New complementary examinations were performed during hospitalisation.", + "Schirmer test was negative.", + "Ophthalmological evaluation with computerised visual field and OCT was within normal parameters.", + "Serologies for Whipple were negative.", + "Neuroconduction confirmed previously described findings.", + "A dose of anti-GFAP antibodies in CSF was performed.", + "Anti-GFAP antibodies in CSF were positive with a titre of 1:100.", + "A diagnosis of astheno-myelopathy with autoimmune glial acid fibrillar protein was made.", + "The patient continues follow-up in our centre.", + "There have been no new clinical or imaging relapses.", + "A waiting policy was decided for treatment according to evolution." + ], + "summary": "We present the case of a 35-year-old patient with central and peripheral nervous system involvement and a recent diagnosis of thyroid cancer, who, in the face of a compatible clinical picture of meningoencephalomyelitis, the characteristic findings in magnetic resonance and after the exclusion of alternative diseases, finally arrived at the diagnosis by the positive determination of anti GFAP in CSF. She underwent surgical treatment and radioactive iodine treatment for her tumour and subsequently received corticosteroid treatment with partial improvement of the neurological signs and symptoms.\n", + "summary_subclaims": [ + "The patient is a 35-year-old.", + "The patient has central and peripheral nervous system involvement.", + "The patient has a recent diagnosis of thyroid cancer.", + "The patient had a compatible clinical picture of meningoencephalomyelitis.", + "The patient had characteristic findings in magnetic resonance.", + "Alternative diseases were excluded.", + "The diagnosis was made by the positive determination of anti GFAP in CSF.", + "The patient underwent surgical treatment for her tumour.", + "The patient received radioactive iodine treatment for her tumour.", + "The patient received corticosteroid treatment.", + "The patient had partial improvement of the neurological signs and symptoms." + ] + }, + { + "id": "multiclinsum_test_2308_en.txt", + "fulltext": "A 74-year-old female presented to the emergency department for progressive left leg weakness that had resulted in multiple falls. An electrocardiogram (ECG) was obtained per . The ECG had a fixed frequency square wave artifact in all leads, not present on previous ECGs. The patient reported no implanted pacemaker and no neural stimulator, but he was wearing a BioTel event monitor (BioTelemetry, Inc, Malvern, PA), which had been placed in the prior month for syncope. The nurse turned off and removed the event monitor and replaced the ECG machine main cable. A repeat ECG was unchanged. The nurse then exchanged the room’s cardiac monitor leads. A repeat ECG showed complete resolution of the artifact, shown in . The initial set of cardiac monitor leads showed no visible damage but appeared to be the cause of this unique artifact.", + "fulltext_subclaims": [ + "The patient is a 74-year-old female.", + "The patient presented with progressive left leg weakness.", + "The patient had multiple falls.", + "An electrocardiogram (ECG) was obtained.", + "The ECG had a fixed frequency square wave artifact in all leads.", + "The artifact was not present on previous ECGs.", + "The patient reported no implanted pacemaker.", + "The patient reported no neural stimulator.", + "The patient was wearing a BioTel event monitor.", + "The BioTel event monitor had been placed in the prior month for syncope.", + "The nurse turned off and removed the event monitor.", + "The nurse replaced the ECG machine main cable.", + "A repeat ECG was unchanged.", + "The nurse exchanged the room’s cardiac monitor leads.", + "A repeat ECG showed complete resolution of the artifact.", + "The initial set of cardiac monitor leads showed no visible damage.", + "The initial set of cardiac monitor leads appeared to be the cause of this unique artifact." + ], + "summary": "We present the case of a 74-year-old female patient who presented to the emergency department with lower extremity weakness found to have a fixed frequency square wave artifact in all leads of her electrocardiogram (ECG). After troubleshooting, faulty external cardiac monitor leads were identified as the cause of this unique artifact.", + "summary_subclaims": [ + "The patient was a 74-year-old female.", + "The patient presented to the emergency department with lower extremity weakness.", + "A fixed frequency square wave artifact was found in all leads of her electrocardiogram.", + "After troubleshooting, faulty external cardiac monitor leads were identified as the cause of the artifact." + ] + }, + { + "id": "multiclinsum_test_3225_en.txt", + "fulltext": "Five-year-old male patient from the district of Independencia in Lima, Peru, referred to the Instituto Nacional de Salud del Niño San Borja with a diagnosis of very severe myelopenia, clonal nocturnal paroxysmal hemoglobinuria (HPN), no response to immunosuppressive therapy (TIS) and no HLA-matched donor. In addition, he had a history of receiving polytransfusions and did not report allergies or adverse reactions to medicines.\n\nThe patient underwent a first haploidentical T-cell receptor (TCR) α/β - CD19 - conditioning regimen with fludarabine, rabbit antithymocyte globulin, cyclophosphamide and total body irradiation. However, the transplant failed and subsequently he developed persistent febrile neutropenia requiring broad spectrum antimicrobial treatment and even required surgery for acute appendicitis. The patient recovered and three months after the first T-cell receptor (TCR) haploidentical transplant, a second haploidentical transplant was performed which also failed due to failure of engraftment and developed profound neutropenia (absolute neutrophil count (ANC) = 0 cells/µL), with intermittent fever episodes and partial response to broad spectrum antimicrobial treatment regimens for neutropenic colitis, central venous catheter-associated infection and probable invasive pulmonary aspergillosis, serum galactomannan positive, 2.1 optical density (OD).\n\nOn day 110, after the TPH, following episodes of persistent fever and with elevated C-reactive protein values, the patient was afebrile for several days and reached the lowest C-reactive protein value in weeks of antimicrobial therapy (C-reactive protein = 30 mg/L, normal value = < 5mg/L), receiving meropenem, ciprofloxacin, linezolid and voriconazole for prolonged time.\n\nSubsequently, the progressive withdrawal of antimicrobials was decided, but he again presented fever, the values of C-reactive protein increased progressively and, from day 140, the deterioration of renal function (creatinine: 3.17 mg/dL; urea: 117 mg/dL; urea nitrogen: 54.64 mg/dL) was exacerbated, with bilateral eyelid oedema and oral mucositis. Despite the reintroduction of antimicrobials, on day 146 post-TPH, intense abdominal pain with a predominance of epigastrium, disseminated maculo-papular lesions of reddish skin, and pain in the right knee without evidence of signs of phlogosis, but which increased when performing extension movements, appeared. Due to the abdominal compromise, the patient did not continue receiving oral prophylaxis with posaconazole and, due to the clinical deterioration, caspofungin was initiated empirically (day 147) at a dose of 70 mg/SC/day (loading dose), then 50 mg/SC/day. According to the laboratory results, the patient persisted with ANC=0 cells/µL, C-reactive protein increased to 180 mg/dL, the galactomannan study was negative (0.08 DO), the viral loads for cytomegalovirus (CMV), adenovirus (ADV), and Epstein-Barr virus (EBV) were undetectable.\n\nFour sets of blood cultures were taken (including peripheral blood, proximal and distal lumen transcatheter), the first three were negative and the last one (taken from transcatheter blood only) on day 147, three days after the sample was taken, was identified as abundant pseudohifes in blood from the proximal and distal lumen catheters, with identification of Saprochaete capitata/Magnusiomyces capitatus. It should be noted that the central venous catheter did not show signs of inflammation in the insertion area, but that it was prolonged (57 days) and was not removed. Other laboratory examinations at the time of diagnosis are shown in Table 1. The patient died of septic shock (day 150), the same day that the identification of the causative agent of invasive fungal infection was reported.\n", + "fulltext_subclaims": [ + "The patient is a five-year-old male from the district of Independencia in Lima, Peru.", + "The patient was referred to the Instituto Nacional de Salud del Niño San Borja.", + "The patient had a diagnosis of very severe myelopenia.", + "The patient had a diagnosis of clonal nocturnal paroxysmal hemoglobinuria.", + "The patient had no response to immunosuppressive therapy.", + "The patient had no HLA-matched donor.", + "The patient had a history of receiving polytransfusions.", + "The patient did not report allergies.", + "The patient did not report adverse reactions to medicines.", + "The patient underwent a first haploidentical T-cell receptor (TCR) α/β - CD19 - conditioning regimen.", + "The first haploidentical transplant failed.", + "The patient developed persistent febrile neutropenia.", + "The patient required broad spectrum antimicrobial treatment.", + "The patient required surgery for acute appendicitis.", + "Three months after the first T-cell receptor (TCR) haploidentical transplant, a second haploidentical transplant was performed.", + "The second haploidentical transplant failed due to failure of engraftment.", + "The patient developed profound neutropenia with an absolute neutrophil count of 0 cells/µL.", + "The patient had intermittent fever episodes.", + "The patient had a partial response to broad spectrum antimicrobial treatment regimens.", + "The patient had neutropenic colitis.", + "The patient had a central venous catheter-associated infection.", + "The patient had probable invasive pulmonary aspergillosis.", + "The patient had a positive serum galactomannan of 2.1 optical density.", + "On day 110, the patient was afebrile for several days.", + "On day 110, the patient reached the lowest C-reactive protein value in weeks of antimicrobial therapy.", + "On day 110, the patient had a C-reactive protein of 30 mg/L.", + "On day 110, the patient received meropenem, ciprofloxacin, linezolid, and voriconazole.", + "The patient again presented fever.", + "The patient's C-reactive protein values increased progressively.", + "On day 140, the patient had deterioration of renal function.", + "On day 140, the patient had a creatinine of 3.17 mg/dL.", + "On day 140, the patient had a urea of 117 mg/dL.", + "On day 140, the patient had a urea nitrogen of 54.64 mg/dL.", + "On day 140, the patient had bilateral eyelid oedema.", + "On day 140, the patient had oral mucositis.", + "On day 146, the patient had intense abdominal pain with a predominance of epigastrium.", + "On day 146, the patient had disseminated maculo-papular lesions of reddish skin.", + "On day 146, the patient had pain in the right knee.", + "On day 146, the patient did not have signs of phlogis in the right knee.", + "On day 147, caspofungin was initiated empirically at a dose of 70 mg/SC/day.", + "On day 147, the patient had an ANC of 0 cells/µL.", + "On day 147, the patient had a C-reactive protein of 180 mg/L.", + "On day 147, the galactomannan study was negative (0.08 DO).", + "On day 147, the viral loads for cytomegalovirus, adenovirus, and Epstein-Barr virus were undetectable.", + "Four sets of blood cultures were taken.", + "The first three blood cultures were negative.", + "The last blood culture, taken from transcatheter blood only, was identified as abundant pseudohifes.", + "The last blood culture identified Saprochaete capitata/Magnusiomyces capitatus.", + "The central venous catheter was not removed.", + "The patient died of septic shock on day 150.", + "The patient died on the same day that the identification of the causative agent of invasive fungal infection was reported." + ], + "summary": "We present the case of a 5-year-old boy with a diagnosis of medullary aplasia, who underwent a haematopoietic progenitor transplant (HPT), who developed persistent febrile neutropenia, severe abdominal pain, maculo-papular skin lesions and renal impairment. The presence of S. capitata was identified in central venous catheter blood cultures.\n", + "summary_subclaims": [ + "The patient is a 5-year-old boy.", + "The patient has a diagnosis of medullary aplasia.", + "The patient underwent a haematopoietic progenitor transplant.", + "The patient developed persistent febrile neutropenia.", + "The patient had severe abdominal pain.", + "The patient had maculo-papular skin lesions.", + "The patient had renal impairment.", + "S. capitata was identified in central venous catheter blood cultures." + ] + }, + { + "id": "multiclinsum_test_1158_en.txt", + "fulltext": "Registering a cleft lip and palate at 26 wk of gestation and delayed motor development at 2 years of age.\nThe patient, a 2-year-and-8-month-old Mexican girl, was brought by her parents for evaluation because of delays in her motor and language development and congenital malformations. Currently, her motor development is abnormal without head control, she still does not sit down. She also does not speak any words and often becomes ill from the respiratory tract without any serious complications.\nThe proband was the third child of two healthy, unrelated, and young parents (27 and 26 years old at the time of delivery). Their familial history was negative for congenital malformations or intellectual disability. The mother had prenatal care, registering a cleft lip and palate at 26 wk of gestation. The proband was born by cesarean section at 38 wk of gestation with a weight of 3035 g (25th percentile), a length of 50 cm (25th–50th percentile), an OFC of 33 cm (10th percentile), and Apgar scores of 81 and 95. She did not require neonatal management.\nTheir familial history was negative for congenital malformations or intellectual disability.\nUpon physical examination, her weight was 9.2 kg (< 3rd percentile), her length was 87 cm (3rd–10th percentile), and her OFC was 46 cm (< 3rd percentile). She had microcephaly, upward-slanting palpebral fissures, a depressed nasal bridge, a bulbous nose, and a bilateral cleft lip and palate .\nBlood, urine, and thyroid profile analyses were normal. The karyotype was 46, XX.\nThe abdominal ultrasound was normal. The brain magnetic resonance imaging showed cortical atrophy, pachygyria, microgyria and band heterotopia .", + "fulltext_subclaims": [ + "Registering a cleft lip and palate at 26 wk of gestation.", + "Delayed motor development at 2 years of age.", + "The patient is a 2-year-and-8-month-old Mexican girl.", + "The patient was brought for evaluation because of delays in motor and language development and congenital malformations.", + "The patient's motor development is abnormal without head control.", + "The patient still does not sit down.", + "The patient does not speak any words.", + "The patient often becomes ill from the respiratory tract.", + "The patient's illnesses do not have serious complications.", + "The parents are two healthy, unrelated, and young individuals.", + "The mother was 27 years old at the time of delivery.", + "The father was 26 years old at the time of delivery.", + "The familial history was negative for congenital malformations or intellectual disability.", + "The mother had prenatal care.", + "The proband was born by cesarean section at 38 wk of gestation.", + "The proband's weight at birth was 3035 g.", + "The proband's length at birth was 50 cm.", + "The proband's OFC at birth was 33 cm.", + "The proband's Apgar scores were 81 and 95.", + "The proband did not require neonatal management.", + "The patient's weight was 9.2 kg.", + "The patient's length was 87 cm.", + "The patient's OFC was 46 cm.", + "The patient had microcephaly.", + "The patient had upward-slanting palpebral fissures.", + "The patient had a depressed nasal bridge.", + "The patient had a bulbous nose.", + "The patient had a bilateral cleft lip and palate.", + "Blood, urine, and thyroid profile analyses were normal.", + "The karyotype was 46, XX.", + "The abdominal ultrasound was normal.", + "The brain magnetic resonance imaging showed cortical atrophy.", + "The brain magnetic resonance imaging showed pachygyria.", + "The brain magnetic resonance imaging showed microgyria.", + "The brain magnetic resonance imaging showed band heterotopia." + ], + "summary": "The proband was a 2-years-8-months-old girl. Familial history was negative for congenital malformations or intellectual disability. The patient had microcephaly, upward-slanting palpebral fissures, depressed nasal bridge, bulbous nose and bilateral cleft lip and palate. Brain magnetic resonance imaging showed cortical atrophy and band heterotopia. Her motor and intellectual development is delayed. A submicroscopic deletion in 11p13 involving the elongator acetyltransferase complex subunit 4 gene (ELP4) and a loss of heterozygosity in Xq25-q26.3 were detected.", + "summary_subclaims": [ + "The proband was a 2-years-8-months-old girl.", + "Familial history was negative for congenital malformations or intellectual disability.", + "The patient had microcephaly.", + "The patient had upward-slanting palpebral fissures.", + "The patient had a depressed nasal bridge.", + "The patient had a bulbous nose.", + "The patient had bilateral cleft lip and palate.", + "Brain magnetic resonance imaging showed cortical atrophy.", + "Brain magnetic resonance imaging showed band heterotopia.", + "Her motor and intellectual development is delayed.", + "A submicroscopic deletion in 11p13 involving the elongator acetyltransferase complex subunit 4 gene (ELP4) was detected.", + "A loss of heterozygosity in Xq25-q26.3 was detected." + ] + }, + { + "id": "multiclinsum_test_2868_en.txt", + "fulltext": "A 48-year-old woman was admitted to our hospital because of a palpable mass in the lower abdomen.\nShe denied the presence of abdominal pain, abdominal distention, diarrhea, or dyspepsia without weight loss. Her appetite was not affected.\nShe denied any history of hypertension, coronary heart disease, diabetes, or coronary heart disease. She reported no history of smoking, alcohol intake, or a hereditary disorder.\nAbdominal examination showed that her abdomen was diffusely soft, with no distention or tenderness. No other positive sign was observed.\nUpon admission, her routine blood test results and blood biochemical parameters were normal. Her serum carbohydrate antigen (CA) 19-9 level was 251 U/mL, and her serum CA125 level was 412 U/mL. The levels of other tumor markers, including CA242, carcinoembryonic antigen (CEA), alpha-fetoprotein (AFP), and CA724, were within the normal ranges.\nAbdominal enhanced computed tomography (CT) revealed a low-density lesion measuring 5.9 cm × 4.6 cm with a poorly defined margin and an irregular contour in the tail of the pancreas. The lesion was hypo-enhanced in the pancreatic parenchyma phase, with progressive delayed enhancement; this possibly indicated a pancreatic tumor . Additionally, a cystic-solid mass measuring 15.1 cm × 12.0 cm in the right ovary and a cystic mass measuring 5.7 cm × 4.3 cm in the left ovary were detected in the pelvic cavity. Both masses were thin-walled and had multiple enhancing septa. There was no evidence of liver or peritoneal metastases .\nThe initial diagnosis was uncertain, but the focus was on pancreatic or ovarian cancer. Therefore, she underwent fine-needle biopsy of lesions after a consultation of doctors. Endoscopic ultrasound-guided fine needle (22 gauge) biopsies of the lesion in the pancreatic tail revealed that there was an infiltrative heterogenic glandular growth in the fibrous tissue. And the ultrasound-guided biopsy of the ovary indicated the mass was likely to be metastatic. Immunohistochemistry showed the following findings: CK20 (+), CK7 (+), CDX2 (-), ER (-), and PR (-). The multidisciplinary team considered this pancreatic tumor to be possibly resectable or borderline resectable with ovarian metastases.", + "fulltext_subclaims": [ + "The patient is a 48-year-old woman.", + "She was admitted to the hospital because of a palpable mass in the lower abdomen.", + "She denied the presence of abdominal pain.", + "She denied the presence of abdominal distention.", + "She denied the presence of diarrhea.", + "She denied the presence of dyspepsia without weight loss.", + "Her appetite was not affected.", + "She denied any history of hypertension.", + "She denied any history of coronary heart disease.", + "She denied any history of diabetes.", + "She reported no history of smoking.", + "She reported no history of alcohol intake.", + "She reported no history of a hereditary disorder.", + "Abdominal examination showed that her abdomen was diffusely soft.", + "No other positive sign was observed.", + "Her serum CA19-9 level was 251 U/mL.", + "Her serum CA125 level was 412 U/mL.", + "The levels of other tumor markers, including CA242, CEA, AFP, and CA724, were within the normal ranges.", + "Abdominal enhanced CT revealed a low-density lesion measuring 5.9 cm × 4.6 cm with a poorly defined margin and an irregular contour in the tail of the pancreas.", + "The lesion was hypo-enhanced in the pancreatic parenchyma phase, with progressive delayed enhancement.", + "This possibly indicated a pancreatic tumor.", + "A cystic-solid mass measuring 15.1 cm × 12.0 cm in the right ovary was detected.", + "A cystic mass measuring 5.7 cm × 4.3 cm in the left ovary was detected.", + "Both masses were thin-walled and had multiple enhancing septa.", + "There was no evidence of liver or peritoneal metastases.", + "The initial diagnosis was uncertain.", + "The focus was on pancreatic or ovarian cancer.", + "She underwent fine-needle biopsy of lesions after a consultation of doctors.", + "Endoscopic ultrasound-guided fine needle (22 gauge) biopsies of the lesion in the pancreatic tail revealed an infiltrative heterogenic glandular growth in the fibrous tissue.", + "The ultrasound-guided biopsy of the ovary indicated the mass was likely to be metastatic.", + "Immunohistochemistry showed CK20 (+).", + "Immunohistochemistry showed CK7 (+).", + "Immunohistochemistry showed CDX2 (-).", + "Immunohistochemistry showed ER (-).", + "Immunohistochemistry showed PR (-).", + "The multidisciplinary team considered this pancreatic tumor to be possibly resectable or borderline resectable with ovarian metastases." + ], + "summary": "A 48-year-old woman with an abdominal mass presented to our hospital. Computed tomography revealed lesions in the pancreas and lower abdomen. Radiological examination and histological investigation of biopsy specimens revealed either an ovarian metastasis from a pancreatic neoplasm or two primary tumors, with metastasis strongly suspected. The patient simultaneously underwent distal pancreatectomy plus splenectomy by a general surgeon and salpingo-oophorectomy with hysterectomy by a gynecologist. Histological examination of the surgical specimen revealed a pancreatic adenocarcinoma (intermediate differentiation, mucinous) and a metastatic mucinous adenocarci-noma in the ovary.", + "summary_subclaims": [ + "The patient is a 48-year-old woman.", + "The patient had an abdominal mass.", + "Computed tomography revealed lesions in the pancreas.", + "Computed tomography revealed lesions in the lower abdomen.", + "Radiological examination and histological investigation of biopsy specimens revealed either an ovarian metastasis from a pancreatic neoplasm or two primary tumors.", + "Metastasis was strongly suspected.", + "The patient underwent distal pancreatectomy plus splenectomy.", + "The patient underwent salpingo-oophorectomy with hysterectomy.", + "Histological examination of the surgical specimen revealed a pancreatic adenocarcinoma.", + "The pancreatic tumor was intermediate differentiation.", + "The pancreatic tumor was mucinous.", + "Histological examination revealed a metastatic mucinous adenocarcinoma in the ovary." + ] + }, + { + "id": "multiclinsum_test_2285_en.txt", + "fulltext": "A 16-year-old girl complained of pain in her right knee for one year and claudication while walking for two weeks. The patient said that pain had gradually developed in the lower part of the thigh one year ago. The pain increased during walking and was relieved after rest. Physical examination showed that the right knee joint had a valgum deformity , the lower part of the right thigh did not touch an obvious mass, the inner side of the lower part of the right thigh had local tenderness, and the flexion and extension function of the knee joint was acceptable. X-ray showed valgum deformity in the right knee, osteolytic bone destruction in the metaphyseal segment of the right femoral shaft, discontinuity of the medial cortex and sclerosis at the edge of the lesion, and separation could be seen inside. We classified the knee valgum deformity according to Ranawat . On the full-length positive X-ray of both lower limbs, a femoral tibial angle < 10° is type I, a femoral tibial angle of 10°-20° is type II, and a femoral tibial angle > 20° is type III. The femoral tibial angle of this patient was 19.7°, which belonged to Ranawat type II . It can be seen that the eccentric, osteolytic and well-defined focus of the femoral metaphysis on the X-ray . CT showed that the medial bone cortex at the metaphyseal segment of the femur was fractured, with eccentric osteolytic destruction and sclerotic margins . MRI showed a low signal in the metaphyseal segment of the femur, a fractured medial cortex and a clear edge on the T1 image . Puncture pathology showed that nonossifying fibroma was possible but that giant cell tumor of bone could not be excluded . The patient was young and had a long history. The focus originated from one side of the bone cortex, and map-like eccentric osteolytic destruction was present at the metaphyseal segment of femur, with a clear boundary, sclerotic edge, no involvement at the bone end, separation in the focus, and secondary valgum deformity. It was more likely to be non ossifying fibroma after multidisciplinary discussion. The operation plan was curettage, osteotomy, orthopedic bone grafting and internal fixation.\nWe completed the relevant preoperative situation of the patient and planned to carry out expanded tumor curettage and osteotomy. The patient's valgum deformity was located in the distal femur, and there was no deformity of the tibia. The amount and direction of osteotomy were designed according to the Miniaci method. The ankle joint center (B) and knee joint center (C) were connected on the full-length film of both lower limbs, and the line was extended to the proximal end. The position of the osteotomy hinge point (A) was 5 mm above the lateral condyle of the femur and approximately 5–10 mm inward from the lateral cortex. This point was the center of the circle (A). The line was rotated between this point (A) and the center of the femoral head (O) and intersected the extension of line BC at D. The rotation angle (∠ OAD = 19.5°) was the osteotomy degree . The hinge point was taken as the apex, and an isosceles triangle was made toward the medial cortex of the distal femur. The top angle of the triangle was the osteotomy degree mentioned above, and the length of the bottom edge was 1.26 cm, which was the length of the medial cortex of the femur to be corrected .\nWe made a medial incision in the distal femur. An oval window was opened on the medial bone cortex, with a window area of approximately 5 × 1 cm. The diseased tissue in the medullary cavity was scraped off, the medullary cavity was ground with a grinding drill, the medullary cavity was burned with an electric knife, and finally, the tissue was soaked in anhydrous alcohol for five minutes. According to the preoperative design, two Kirschner wires were inserted and served as the osteotomy positioning guide needle. The angle was checked via fluoroscopy and determined to be too small; then, another Kirschner wire was implanted. On fluoroscopy, the osteotomy angle was good. The outermost two Kirschner wires were equivalent to two sides of the isosceles triangle planned in the preoperative design. The Kirschner wires intersected 5–10 mm inside the cortex of the lateral condyle of the femur, which was the hinge point of the osteotomy . The distance between the two Kirschner wires (red lines on Fig. C) was the bottom edge of the isosceles triangle planned preoperatively and was approximately 1.26 cm . A wedge-shaped osteotomy was made with a pendulum saw was used to control the osteotomy depth, stopping when it was close to the contralateral cortex and protecting the contralateral hinge; then the osteotomy end was closed slowly . After fluoroscopic examination indicated that the mechanical axis of right lower limb was satisfactory, the medial plate of the distal femur was implanted . The flexion and extension function of the knee joint was good, and the fracture end was stable. After washing, the broken end medullary cavity was implanted with allogeneic bone, and the drainage tube was placed and sutured layer by layer.\nThe patient performed muscle strengthening by isometrically contracting the quadriceps femoris in the hospital bed. When there was no obvious pain, knee flexion and extension exercises were started. The incision was changed regularly to observe whether there was an infection. Postoperative pathology showed giant cell lesions, proliferation of stromal spindle cells, local bleeding and new bone formation . Combined with the medical history, the final diagnosis is considered nonossifying fibroma. The full-length X-ray of the lower limbs showed that the mechanical axis of right lower limb had been corrected. The femoral tibial angle was 5°, the range of motion of the knee was 0° -130°. There was no tumor recurrence five months after operation, X-ray showed that the lateral fracture line was blurred but not completely healed, and the bone graft in the medullary cavity was partially absorbed. One year after the operation, there was also no tumor recurrence, the lateral fracture line was completely healed, and obvious osteogenesis was present in the medullary cavity .", + "fulltext_subclaims": [ + "The patient is a 16-year-old girl.", + "She complained of pain in her right knee for one year.", + "She had claudication while walking for two weeks.", + "The pain had gradually developed in the lower part of the thigh one year ago.", + "The pain increased during walking.", + "The pain was relieved after rest.", + "Physical examination showed that the right knee joint had a valgum deformity.", + "The lower part of the right thigh did not touch an obvious mass.", + "The inner side of the lower part of the right thigh had local tenderness.", + "The flexion and extension function of the knee joint was acceptable.", + "X-ray showed valgum deformity in the right knee.", + "X-ray showed osteolytic bone destruction in the metaphyseal segment of the right femoral shaft.", + "X-ray showed discontinuity of the medial cortex and sclerosis at the edge of the lesion.", + "Separation could be seen inside the lesion on X-ray.", + "The femoral tibial angle of this patient was 19.7°.", + "The femoral tibial angle of 19.7° belonged to Ranawat type II.", + "CT showed that the medial bone cortex at the metaphyseal segment of the femur was fractured.", + "CT showed eccentric osteolytic destruction.", + "CT showed sclerotic margins.", + "MRI showed a low signal in the metaphyseal segment of the femur.", + "MRI showed a fractured medial cortex.", + "MRI showed a clear edge on the T1 image.", + "Puncture pathology showed that nonossifying fibroma was possible.", + "Puncture pathology showed that giant cell tumor of bone could not be excluded.", + "The focus originated from one side of the bone cortex.", + "Map-like eccentric osteolytic destruction was present at the metaphyseal segment of the femur.", + "The boundary was clear.", + "The edge was sclerotic.", + "There was no involvement at the bone end.", + "Separation was present in the focus.", + "Secondary valgum deformity was present.", + "It was more likely to be nonossifying fibroma after multidisciplinary discussion.", + "The operation plan was curettage, osteotomy, orthopedic bone grafting, and internal fixation.", + "The patient's valgum deformity was located in the distal femur.", + "There was no deformity of the tibia.", + "The amount and direction of osteotomy were designed according to the Miniaci method.", + "The ankle joint center (B) and knee joint center (C) were connected on the full-length film of both lower limbs.", + "The line was extended to the proximal end.", + "The position of the osteotomy hinge point (A) was 5 mm above the lateral condyle of the femur.", + "The position of the osteotomy hinge point (A) was approximately 5–10 mm inward from the lateral cortex.", + "This point was the center of the circle (A).", + "The line was rotated between this point (A) and the center of the femoral head (O).", + "The line intersected the extension of line BC at D.", + "The rotation angle (∠ OAD = 19.5°) was the osteotomy degree.", + "The hinge point was taken as the apex.", + "An isosceles triangle was made toward the medial cortex of the distal femur.", + "The top angle of the triangle was the osteotomy degree mentioned above.", + "The length of the bottom edge was 1.26 cm.", + "This was the length of the medial cortex of the femur to be corrected.", + "A medial incision was made in the distal femur.", + "An oval window was opened on the medial bone cortex.", + "The window area was approximately 5 × 1 cm.", + "The diseased tissue in the medullary cavity was scraped off.", + "The medullary cavity was ground with a grinding drill.", + "The medullary cavity was burned with an electric knife.", + "The tissue was soaked in anhydrous alcohol for five minutes.", + "Two Kirschner wires were inserted and served as the osteotomy positioning guide needle.", + "The angle was checked via fluoroscopy and determined to be too small.", + "Another Kirschner wire was implanted.", + "On fluoroscopy, the osteotomy angle was good.", + "The outermost two Kirschner wires were equivalent to two sides of the isosceles triangle planned in the preoperative design.", + "The Kirschner wires intersected 5–10 mm inside the cortex of the lateral condyle of the femur.", + "This was the hinge point of the osteotomy.", + "The distance between the two Kirschner wires was the bottom edge of the isosceles triangle planned preoperatively.", + "The distance was approximately 1.26 cm.", + "A wedge-shaped osteotomy was made with a pendulum saw.", + "The pendulum saw was used to control the osteotomy depth.", + "The osteotomy depth was stopped when it was close to the contralateral cortex.", + "The contralateral hinge was protected.", + "The osteotomy end was closed slowly.", + "After fluoroscopic examination, the mechanical axis of the right lower limb was satisfactory.", + "The medial plate of the distal femur was implanted.", + "The flexion and extension function of the knee joint was good.", + "The fracture end was stable.", + "After washing, the broken end medullary cavity was implanted with allogeneic bone.", + "The drainage tube was placed and sutured layer by layer.", + "The patient performed muscle strengthening by isometrically contracting the quadriceps femoris in the hospital bed.", + "Knee flexion and extension exercises were started when there was no obvious pain.", + "The incision was changed regularly to observe whether there was an infection.", + "Postoperative pathology showed giant cell lesions.", + "Postoperative pathology showed proliferation of stromal spindle cells.", + "Postoperative pathology showed local bleeding.", + "Postoperative pathology showed new bone formation.", + "Combined with the medical history, the final diagnosis is considered nonossifying fibroma.", + "The full-length X-ray of the lower limbs showed that the mechanical axis of the right lower limb had been corrected.", + "The femoral tibial angle was 5°.", + "The range of motion of the knee was 0° -130°.", + "There was no tumor recurrence five months after operation.", + "X-ray showed that the lateral fracture line was blurred but not completely healed.", + "X-ray showed that the bone graft in the medullary cavity was partially absorbed.", + "One year after the operation, there was also no tumor recurrence.", + "X-ray showed that the lateral fracture line was completely healed.", + "X-ray showed obvious osteogenesis in the medullary cavity." + ], + "summary": "A 16-year-old girl complained of pain in the lower part of her right thigh for one year. She was diagnosed as non ossifying fibroma of the right femur with secondary valgus deformity of the right knee, and was treated in our hospital. We performed curettage, bone grafting and internal fixation,and corrected the valgum deformity at the same time. The patient's incision healed well, the pain was disappeared, and the mechanical axis of lower limbs was corrected. No tumor recurrence was found on X- ray examination one year after operation, and the fracture end was healed. The patient could walk normally, and she was satisfied with her limb function.", + "summary_subclaims": [ + "The patient is a 16-year-old girl.", + "She complained of pain in the lower part of her right thigh for one year.", + "She was diagnosed as non ossifying fibroma of the right femur.", + "She had secondary valgus deformity of the right knee.", + "We performed curettage, bone grafting and internal fixation.", + "We corrected the valgum deformity at the same time.", + "The patient's incision healed well.", + "The pain was disappeared.", + "The mechanical axis of lower limbs was corrected.", + "No tumor recurrence was found on X-ray examination one year after operation.", + "The fracture end was healed.", + "The patient could walk normally.", + "She was satisfied with her limb function." + ] + }, + { + "id": "multiclinsum_test_1170_en.txt", + "fulltext": "The patient was a 29-year-old nulliparous woman (height, 158 cm; weight, 58 kg; BMI, 20.4 kg/m2) who had received oral thyroid hormone replacement due to previous subtotal thyroidectomy for Graves’ disease. No abnormalities in platelet count or coagulation had been noted. She was initially referred to our institution due to suspected placenta previa. At 31 weeks of gestation, the placental position was confirmed within the normal range, and the placenta previa was denied. No additional concerns were described during the remainder of her pregnancy. At 41 weeks of pregnancy, vaginal delivery was induced by oxytocin administration. The patient did not ask for epidural analgesia for her childbirth. The malpresentation or malrotation of the fetal head was not confirmed, which would compress the nerve root and induce severe radiating pain. The obstetrician expected uterine hypertonus when her fetus developed non-reassuring fetal status. The patient was advised of emergent cesarean delivery because the discontinuation of oxytocin did not improve the fetal status.\nAfter careful disinfection with 10% povidone-iodine, waiting for the disinfectant to dry, spinal anesthesia was performed with the patient’s left lateral position. The L2/3 interspace was identified by palpating the posterior superior iliac spine to confirm the L5 and S1 vertebrae. A 25-gauge Quincke needle was used to puncture the L2/3 interspace via median approach.\nThe first puncture obtained clear cerebrospinal fluid reflux. A mixture of anesthetics containing 12 mg of 0.5% hyperbaric bupivacaine, 0.1 mg of morphine hydrochloride, and 10 mcg of fentanyl citrate was administered. There were no concerns, such as bleeding or radiating pain, during the puncture or infusion of the anesthetics. The level of the blockade successfully covered the sixth thoracic vertebral dermatome level.\nThe delivery was uneventful for both the patient and infant, and the estimated blood loss was 500 mL. The patient noticed discomfort and numbness in the left lower extremity 7 h after the spinal procedure, but she did not tell the finding to her obstetrician. On a postoperative day 1, she complained of sensory numbness on the lateral side of the left lower leg and difficulty with dorsiflexion and plantar flexion of the left foot. A neurologist was consulted by her obstetrician and assessed the manual muscle strength test and found that her left tibialis anterior and gastrocnemius muscles had weakened by 3/5. The neurologist also noted sensory loss on the lateral side of the left lower leg. Collectively, the injury to the L5 and S1 nerve root was suspected. On postoperative day 3, the patient underwent MRI to rule out the possibility of such complications as epidural hematoma formation. The image showed a T2W1 low signal in the left side of the spinal canal at the L5/S1 level due to adhesive arachnoiditis . No abnormal signal was observed in the spinal cord. She could walk unaided within a few days; however, the dullness and paralysis persisted at discharge on the sixth postoperative day. The symptoms gradually improved and entirely disappeared within 2 months.", + "fulltext_subclaims": [ + "The patient was a 29-year-old nulliparous woman.", + "She had received oral thyroid hormone replacement due to previous subtotal thyroidectomy for Graves’ disease.", + "No abnormalities in platelet count or coagulation had been noted.", + "She was initially referred to our institution due to suspected placenta previa.", + "At 31 weeks of gestation, the placental position was confirmed within the normal range.", + "The placenta previa was denied.", + "No additional concerns were described during the remainder of her pregnancy.", + "At 41 weeks of pregnancy, vaginal delivery was induced by oxytocin administration.", + "The patient did not ask for epidural analgesia for her childbirth.", + "The malpresentation or malrotation of the fetal head was not confirmed.", + "The obstetrician expected uterine hypertonus when her fetus developed non-reassuring fetal status.", + "The patient was advised of emergent cesarean delivery because the discontinuation of oxytocin did not improve the fetal status.", + "Spinal anesthesia was performed with the patient’s left lateral position.", + "The L2/3 interspace was identified by palpating the posterior superior iliac spine to confirm the L5 and S1 vertebrae.", + "A 25-gauge Quincke needle was used to puncture the L2/3 interspace via median approach.", + "The first puncture obtained clear cerebrospinal fluid reflux.", + "A mixture of anesthetics containing 12 mg of 0.5% hyperbaric bupivacaine, 0.1 mg of morphine hydrochloride, and 10 mcg of fentanyl citrate was administered.", + "There were no concerns, such as bleeding or radiating pain, during the puncture or infusion of the anesthetics.", + "The level of the blockade successfully covered the sixth thoracic vertebral dermatome level.", + "The estimated blood loss was 500 mL.", + "The patient noticed discomfort and numbness in the left lower extremity 7 h after the spinal procedure.", + "She did not tell the finding to her obstetrician.", + "On postoperative day 1, she complained of sensory numbness on the lateral side of the left lower leg.", + "She had difficulty with dorsiflexion and plantar flexion of the left foot.", + "A neurologist was consulted by her obstetrician.", + "The neurologist found that her left tibialis anterior and gastrocnemius muscles had weakened by 3/5.", + "The neurologist noted sensory loss on the lateral side of the left lower leg.", + "The injury to the L5 and S1 nerve root was suspected.", + "The patient underwent MRI to rule out the possibility of such complications as epidural hematoma formation.", + "The image showed a T2W1 low signal in the left side of the spinal canal at the L5/S1 level due to adhesive arachnoiditis.", + "No abnormal signal was observed in the spinal cord.", + "She could walk unaided within a few days.", + "The dullness and paralysis persisted at discharge on the sixth postoperative day.", + "The symptoms gradually improved and entirely disappeared within 2 months." + ], + "summary": "A 29-year-old nulliparous woman underwent an emergent cesarean delivery under spinal anesthesia at the second and third lumbar interspace (L2/3) without any specific concerns. Subsequently, she developed left L5 and sacral first (S1) radiculopathy that persisted for 2 months. Although the neurological findings more likely indicated peripheral neuropathy, magnetic resonance imaging revealed localized adhesive arachnoiditis at the left L5/S1 level. Her symptoms gradually improved and entirely disappeared within 2 months without any particular treatment.", + "summary_subclaims": [ + "The patient is a 29-year-old nulliparous woman.", + "She underwent an emergent cesarean delivery under spinal anesthesia.", + "The spinal anesthesia was administered at the second and third lumbar interspace (L2/3).", + "She developed left L5 and sacral first (S1) radiculopathy.", + "The radiculopathy persisted for 2 months.", + "The neurological findings more likely indicated peripheral neuropathy.", + "Magnetic resonance imaging revealed localized adhesive arachnoiditis at the left L5/S1 level.", + "Her symptoms gradually improved.", + "Her symptoms entirely disappeared within 2 months.", + "There was no particular treatment." + ] + }, + { + "id": "multiclinsum_test_1593_en.txt", + "fulltext": "A previously healthy six-year-old girl was admitted with fever, dyspnea, abdominal pain, and pain in the right arm and shoulder. Four days before admission she had fallen from a tree while playing. Shortly after admission she was transferred to the ICU because she acutely developed signs of shock, anemia and progressive abdominal pain. Splenic rupture was suspected and confirmed by ultrasound showing sub-capsular spleen hematoma and free intra-abdominal fluid. During the ICU stay she developed an abscess on the right shoulder, for which antibiotic treatment was started. The culture of the aspirate, taken before start of antibiotics, from this abscess was positive for Staphylococcus aureus. After 1 month she was transferred to our center under the suspicion of pericarditis, because of persistent fever and cardiomegaly on the chest X-ray. Echocardiography revealed pericardial effusion, located mostly behind the left ventricular (LV) posterior wall (Additional file ), with a to and fro blood flow through a fistula between the left ventricular lumen and a cavity in the pericardial space, and echogenic densities suggestive for fibrin strands and clots (see Fig. ). Cardiac function was good with mild mitral valve regurgitation. Findings were suggestive for advanced purulent bacterial pericarditis complicated by covered left ventricular perforation (pseudo-aneurysm).\nHigh doses of intravenous cefotaxime and flucloxacillin, already started in the referring hospital, were continued. She developed arthritis of the left knee and right elbow which were both aspirated but with negative cultures. Two weeks after admission her clinical condition did not improve with persistent leukocytosis and high C-reactive protein levels. A pericardial abscess with ongoing bacteremia was suspected and surgical intervention was scheduled.\nA median sternotomy was performed, leaving the pleural space closed. The patient was placed on extracorporeal circulation using standard bicaval cannulation. The operation was performed on a beating heart. On opening of the pericardium multiple small abscesses and adhesions were identified and removed, as were thick vegetations on the left ventricular posterior wall. The fistula in the LV myocardium connecting the LV lumen with an abscess on the posterior-lateral wall of the LV was found and closed with prolene sutures with felt (see Fig. ). The pericardial space was irrigated multiple times with a solution of sodium-chloride and iodine. Cultures of the abscesses were negative. Post-operatively she had a quick recovery without fever episodes. She was discharged from the hospital in good condition 2 weeks after surgery. Antibiotics were continued for almost 4 months because of persistent osteomyelitis of the right upper arm and a septic arthritis of the right elbow. Echocardiograms during follow-up revealed no abnormalities.", + "fulltext_subclaims": [ + "A previously healthy six-year-old girl was admitted with fever, dyspnea, abdominal pain, and pain in the right arm and shoulder.", + "Four days before admission she had fallen from a tree while playing.", + "She was transferred to the ICU because she acutely developed signs of shock, anemia and progressive abdominal pain.", + "Splenic rupture was suspected and confirmed by ultrasound showing sub-capsular spleen hematoma and free intra-abdominal fluid.", + "During the ICU stay she developed an abscess on the right shoulder.", + "Antibiotic treatment was started.", + "The culture of the aspirate, taken before start of antibiotics, from this abscess was positive for Staphylococcus aureus.", + "After 1 month she was transferred to our center under the suspicion of pericarditis.", + "Echocardiography revealed pericardial effusion, located mostly behind the left ventricular posterior wall.", + "Echocardiography showed a to and fro blood flow through a fistula between the left ventricular lumen and a cavity in the pericardial space.", + "Echocardiography showed echogenic densities suggestive for fibrin strands and clots.", + "Cardiac function was good with mild mitral valve regurgitation.", + "Findings were suggestive for advanced purulent bacterial pericarditis complicated by covered left ventricular perforation.", + "High doses of intravenous cefotaxime and flucloxacillin were continued.", + "She developed arthritis of the left knee and right elbow.", + "Both joints were aspirated but with negative cultures.", + "Two weeks after admission her clinical condition did not improve with persistent leukocytosis and high C-reactive protein levels.", + "A pericardial abscess with ongoing bacteremia was suspected.", + "A median sternotomy was performed, leaving the pleural space closed.", + "The patient was placed on extracorporeal circulation using standard bicaval cannulation.", + "The operation was performed on a beating heart.", + "On opening of the pericardium multiple small abscesses and adhesions were identified and removed.", + "Thick vegetations on the left ventricular posterior wall were removed.", + "The fistula in the LV myocardium connecting the LV lumen with an abscess on the posterior-lateral wall of the LV was found and closed with prolene sutures with felt.", + "The pericardial space was irrigated multiple times with a solution of sodium-chloride and iodine.", + "Cultures of the abscesses were negative.", + "Post-operatively she had a quick recovery without fever episodes.", + "She was discharged from the hospital in good condition 2 weeks after surgery.", + "Antibiotics were continued for almost 4 months because of persistent osteomyelitis of the right upper arm and a septic arthritis of the right elbow.", + "Echocardiograms during follow-up revealed no abnormalities." + ], + "summary": "We present a case of a six-year-old girl who was diagnosed with pericarditis and a fistula between the pericardial and the intra-luminal space of the left ventricle of the heart. She was successfully treated with antibiotics and cardio-thoracic surgery. We found 23 published cases (21 with follow-up) of infectious pseudo-aneurysm of the heart, of which 19 underwent surgery, 5 had fatal outcome, and 2 who refused surgery survived. The majority of cases were associated with Staphylococcus aureus. The exact mechanisms of this rare complication remain unknown.", + "summary_subclaims": [ + "The patient was a six-year-old girl.", + "The patient was diagnosed with pericarditis.", + "The patient had a fistula between the pericardial and the intra-luminal space of the left ventricle of the heart.", + "The patient was successfully treated with antibiotics.", + "The patient was successfully treated with cardio-thoracic surgery.", + "There were 23 published cases of infectious pseudo-aneurysm of the heart.", + "21 of the 23 published cases had follow-up.", + "19 of the 23 published cases underwent surgery.", + "5 of the 23 published cases had fatal outcome.", + "2 of the 23 published cases who refused surgery survived.", + "The majority of cases were associated with Staphylococcus aureus.", + "The exact mechanisms of this rare complication remain unknown." + ] + }, + { + "id": "multiclinsum_test_41_en.txt", + "fulltext": "A 76-year-old White male was referred for esophagogastroduodenoscopy (EGD) after an episode of upper gastrointestinal bleeding.\nThe patient reported recurrent epigastric pain, transient fatigue and melena.\nThe patient’s comorbidities were type 2 diabetes mellitus, arterial hypertension and benign prostatic hyperplasia. Past medical history was relevant for coronavirus disease 2019, ischemic stroke, appendectomy, viscerocranial abscess and surgically-treated cataract.\nThe patient had a history of smoking in the past (30 pack-years). However, he had not smoked for 4 years and denied drinking alcohol. There was no relevant family history.\nThe patient’s height was 183 cm, weight was 80 kg, and body mass index was 23.89. Vitals upon admission were: heart rate, 50 beats/min; blood pressure, 118/48 mmHg; respiratory rate, 14/min; and body temperature, 36 °C. There was no abdominal tenderness and no peripheral edema.\nLaboratory results were not relevant. Serum protein or albumin levels were not tested because Ménétrier’s disease was not suspected at the time.\nEGD revealed a polypoid mass (4 cm × 1 cm) with enlarged mucosal folds in the body of the stomach between the lesser curvature and posterior wall . The mass was cohesive and somewhat stiff in contact with the forceps. A small ulcer at the distal end of the mass was identified as the source of the bleeding . Standard and deep biopsy were taken from the distal end of the mass, and both were negative for neoplasia. Except for the mass, the mucosa was normal, and gastric folds were not enlarged.\nComputed tomography of the abdomen with contrast enhancement showed a submucosal lipoma (49 mm × 19 mm) in the body of the stomach, elevating the mucosa . The stomach was otherwise normal. There was no visible infiltration of surrounding tissue and no enlarged lymph nodes.", + "fulltext_subclaims": [ + "A 76-year-old White male was referred for esophagogastroduodenoscopy (EGD) after an episode of upper gastrointestinal bleeding.", + "The patient reported recurrent epigastric pain.", + "The patient reported transient fatigue.", + "The patient reported melena.", + "The patient’s comorbidities were type 2 diabetes mellitus, arterial hypertension and benign prostatic hyperplasia.", + "Past medical history was relevant for coronavirus disease 2019.", + "Past medical history was relevant for ischemic stroke.", + "Past medical history was relevant for appendectomy.", + "Past medical history was relevant for viscerocranial abscess.", + "Past medical history was relevant for surgically-treated cataract.", + "The patient had a history of smoking in the past (30 pack-years).", + "The patient had not smoked for 4 years.", + "The patient denied drinking alcohol.", + "There was no relevant family history.", + "The patient’s height was 183 cm.", + "The patient’s weight was 80 kg.", + "The patient’s body mass index was 23.89.", + "Vitals upon admission were: heart rate, 50 beats/min; blood pressure, 118/48 mmHg; respiratory rate, 14/min; and body temperature, 36 °C.", + "There was no abdominal tenderness.", + "There was no peripheral edema.", + "Laboratory results were not relevant.", + "Serum protein or albumin levels were not tested because Ménétrier’s disease was not suspected at the time.", + "EGD revealed a polypoid mass (4 cm × 1 cm) with enlarged mucosal folds in the body of the stomach between the lesser curvature and posterior wall.", + "The mass was cohesive and somewhat stiff in contact with the forceps.", + "A small ulcer at the distal end of the mass was identified as the source of the bleeding.", + "Standard and deep biopsy were taken from the distal end of the mass.", + "Both biopsies were negative for neoplasia.", + "Computed tomography of the abdomen with contrast enhancement showed a submucosal lipoma (49 mm × 19 mm) in the body of the stomach, elevating the mucosa.", + "There was no visible infiltration of surrounding tissue.", + "There were no enlarged lymph nodes." + ], + "summary": "Esophagogastroduodenoscopy was performed on a 76-year-old male patient after an episode of upper gastrointestinal bleeding, manifesting as fatigue and melena. A large polypoid mass (4 cm × 1 cm) with enlarged mucosal folds was found in the body of the stomach, between the lesser curvature and posterior wall. A small ulcer at the distal end of the mass was identified as the source of the bleeding. Biopsy was negative for neoplasia. Computed tomography showed a submucosal lesion beneath the affected mucosa, most likely a lipoma. The mass was removed en bloc with tunneling endoscopic submucosal dissection. Final pathology determined that the mass included Ménétrier's disease and a submucosal lipoma. The patient was scheduled for follow-up esophagogastroduodenoscopy.", + "summary_subclaims": [ + "The patient was a 76-year-old male.", + "The patient had an episode of upper gastrointestinal bleeding.", + "The bleeding manifested as fatigue and melena.", + "Esophagogastroduodenoscopy was performed.", + "A large polypoid mass (4 cm × 1 cm) with enlarged mucosal folds was found in the body of the stomach.", + "The mass was located between the lesser curvature and posterior wall.", + "A small ulcer at the distal end of the mass was identified as the source of the bleeding.", + "Biopsy was negative for neoplasia.", + "Computed tomography showed a submucosal lesion beneath the affected mucosa.", + "The submucosal lesion was most likely a lipoma.", + "The mass was removed en bloc with tunneling endoscopic submucosal dissection.", + "Final pathology determined that the mass included Ménétrier's disease.", + "Final pathology determined that the mass included a submucosal lipoma.", + "The patient was scheduled for follow-up esophagogastroduodenoscopy." + ] + }, + { + "id": "multiclinsum_test_2655_en.txt", + "fulltext": "A 58-year-old woman was admitted to the hospital with fever, headache for 21 days and left limb weakness for 2 days. The patient had chronic headache (30 years) and dental caries with intermittent toothache (6 years). Twenty-one days (Jun 20) before admission, the patient had fever, swelling pain on his forehead, cough and expectoration, then she was treated in a local clinic. Subsequently, the fever and headache symptoms aggravated (the maximum body temperature reached 38 °C), accompanied by nausea, vomiting, rash, night sweats and arthralgia. The patient was transferred to Beijing Shunyi hospital (Beijing, China), and treated with cefonicid (anti-infective) and amlodipine (reduced blood press), but the fever and headache continued. 2 days (Jul 9) before admission, the patient suddenly developed left-sided limb weakness (the strength grade of left-limb was IV stage) that did not affect standing or walking.\nOn Jul 11, the patient was transferred to our hospital. She exhibited somnolence, bilateral equal-sized round pupils (diameter 3 mm) and sensitivity to light. Her eyes movement in all directions were not limited, and there was no nystagmus, symmetric bilateral nasolabial folds, normal muscle strength in the four limbs (the strength grade of four limbs was V stage), and unstable ataxic movement. In addition, she had no obvious objective sensory disturbance (sensory plane) and the pathologic reflexes were not elicited. The sign of meningeal irritation (Kemig’ and Brudzinsk’ signs) and Brudzinski’s sign were positive. Laboratory test results revealed that the white blood cell counts (11.73 × 109/L), neutrophil counts (9.22 × 109/L) and high-sensitivity C-reactive protein levels (> 5.00 mg/L) were elevated, the level of procalcitonin (PCT) was < 0.1 ng/mL, and the autoimmune encephalitis antibodies (AMPAR1-Ab, AMPAR2-Ab, CASPR2-Ab, DPPX-Ab, GABABR-Ab, IgLON5–Ab, LGI1-Ab, NMDAR-Ab), paraneoplastic antibodies (anti-Amphiphysin, anti-CV2, anti-GAD65, anti-Hu, anti-PNMA2 (Ma-2/Ta), anti-Recoverin, anti-Ri, anti-SOX1, anti-Titin, anti-Tr (DNER), anti-Yo, anti-Zic4 ) and demyelinating antibodies (AQP4-Ab, GFAP-Ab, MBP-Ab, MOG-Ab) were negative. On Jul 12, a lumbar puncture was performed and the test results were shown in Table . The mNGS (MBX52313, Tianjin Genskey Medical Technology Co., Ltd, Tianjing, China) results showed that the Eubacterium brachy, P. gingivalis, Fusobacterium nucleatum and Torque teno virus 29 were detected, but the fungi and mycobacterium tuberculosis were not detected.\nThe brain computerized tomography (CT) scanning indicated the new right thalamus infarct . The brain cranial-enhanced magnetic resonance imaging (MRI) showed the right lateral paraventricular and right thalamic infarct, and abnormal signal in occipital horns of bilateral lateral ventricles were increased . In addition, the brain enhanced nuclear magnetic resonance (NMR) scanning suggested that meninges were thickened and enhanced at the base of the brain, and with meningitis changes . The neck CT angiography (CTA) revealed arteriosclerotic changes, slender right vertebral artery (segment V4 with obliteration), the slender intracranial arteries with uneven thickness, the M1 segment of the left middle cerebral artery with localized moderate stenosis, and the P1 and P2 segments of the left posterior cerebral artery with localized severe stenosis .\nBased on these findings, the patient was finally diagnosed with suppurative meningoencephalitis caused by infection of oral anaerobes (CNS infection), acute cerebral infarction and intra oral abscess (gum and surrounding soft tissue infection). The patient was then given ceftriaxone (4 g, ivgtt, qd, 3days), vancomycin (0.50 g, ivgtt, q8h, 16 days). Subsequently, her symptoms, including headache and fever, alleviated. She was transferred to the Infectious Diseases department (Jul 19), then she was treated with ceftriaxone (2 g, ivgtt, q12h, 2 days) plus metronidazole (0.50 g, ivgtt, q8h, 13 days) to anti-anaerobes. On Aug 1, the patient’s pupils were equal in circle and size, but the abduction of both eyes was limited. Moreover, the left central was facial palsy and left limb was central hemiparesis, and the Kirschner’s sign was positive, the headache and fever was relieved, the white blood cell count in CSF was 888 × 106/L. On Aug 22, the patient’s headache and fever disappeared. During our following-up on Sep 8, the patient remained lucid and no fever or headache. Her left hemiparesis was better than before, and have currently received rehabilitation treatment in Beijing Fengtai Youanmen Hospital (Beijing, China).", + "fulltext_subclaims": [ + "The patient was a 58-year-old woman.", + "She was admitted to the hospital with fever, headache for 21 days, and left limb weakness for 2 days.", + "The patient had chronic headache for 30 years.", + "She had dental caries with intermittent toothache for 6 years.", + "Twenty-one days before admission, she had fever, swelling pain on his forehead, cough, and expectoration.", + "She was treated in a local clinic.", + "The fever and headache symptoms aggravated.", + "The maximum body temperature reached 38 °C.", + "She had nausea, vomiting, rash, night sweats, and arthralgia.", + "She was transferred to Beijing Shunyi hospital.", + "She was treated with cefonicid and amlodipine.", + "The fever and headache continued.", + "Two days before admission, she suddenly developed left-sided limb weakness.", + "The strength grade of the left-limb was IV stage.", + "The limb weakness did not affect standing or walking.", + "On Jul 11, the patient was transferred to our hospital.", + "She exhibited somnolence.", + "Bilateral equal-sized round pupils were observed.", + "The pupils were sensitive to light.", + "Eyes movement in all directions were not limited.", + "There was no nystagmus.", + "Bilateral nasolabial folds were symmetric.", + "Normal muscle strength in the four limbs was observed.", + "The strength grade of the four limbs was V stage.", + "Unstable ataxic movement was noted.", + "There was no obvious objective sensory disturbance.", + "Pathologic reflexes were not elicited.", + "The sign of meningeal irritation (Kemig’ and Brudzinsk’ signs) was positive.", + "Brudzinski’s sign was positive.", + "White blood cell counts were 11.73 × 109/L.", + "Neutrophil counts were 9.22 × 109/L.", + "High-sensitivity C-reactive protein levels were > 5.00 mg/L.", + "The level of procalcitonin was < 0.1 ng/mL.", + "Autoimmune encephalitis antibodies were negative.", + "Paraneoplastic antibodies were negative.", + "Demyelinating antibodies were negative.", + "A lumbar puncture was performed on Jul 12.", + "The mNGS results showed Eubacterium brachy was detected.", + "P. gingivalis was detected.", + "Fusobacterium nucleatum was detected.", + "Torque teno virus 29 was detected.", + "Fungi were not detected.", + "Mycobacterium tuberculosis was not detected.", + "The brain CT scanning indicated a new right thalamus infarct.", + "The brain cranial-enhanced MRI showed right lateral paraventricular and right thalamic infarct.", + "Abnormal signal in occipital horns of bilateral lateral ventricles was increased.", + "The brain enhanced NMR scanning suggested meninges were thickened and enhanced at the base of the brain.", + "Meningitis changes were noted.", + "The neck CTA revealed arteriosclerotic changes.", + "The right vertebral artery segment V4 had obliteration.", + "The intracranial arteries were slender with uneven thickness.", + "The M1 segment of the left middle cerebral artery had localized moderate stenosis.", + "The P1 and P2 segments of the left posterior cerebral artery had localized severe stenosis.", + "The patient was diagnosed with suppurative meningoencephalitis caused by infection of oral anaerobes.", + "She was diagnosed with acute cerebral infarction.", + "She was diagnosed with intra oral abscess.", + "She was given ceftriaxone (4 g, ivgtt, qd, 3 days).", + "She was given vancomycin (0.50 g, ivgtt, q8h, 16 days).", + "Her symptoms, including headache and fever, alleviated.", + "She was transferred to the Infectious Diseases department on Jul 19.", + "She was treated with ceftriaxone (2 g, ivgtt, q12h, 2 days).", + "She was treated with metronidazole (0.50 g, ivgtt, q8h, 13 days).", + "On Aug 1, the patient’s pupils were equal in circle and size.", + "The abduction of both eyes was limited.", + "Left central facial palsy was noted.", + "Left limb central hemiparesis was noted.", + "Kirschner’s sign was positive.", + "The headache and fever were relieved.", + "The white blood cell count in CSF was 888 × 106/L.", + "On Aug 22, the patient’s headache and fever disappeared.", + "During follow-up on Sep 8, the patient remained lucid.", + "She had no fever or headache.", + "Her left hemiparesis was better than before.", + "She received rehabilitation treatment in Beijing Fengtai Youanmen Hospital." + ], + "summary": "A 58-year-old woman was admitted to hospital with fever, headache for 21 days and left limb weakness for 2 days. The blood cell counts (11.73 × 109/L), neutrophil counts (9.22 × 109/L) and high-sensitivity C-reactive protein levels (> 5.00 mg/L) were elevated. The brain computerized tomography (CT) scanning indicated the new right thalamus infarct. The brain cranial-enhanced magnetic resonance imaging (MRI) showed the right lateral paraventricular and right thalamic infarct, and abnormal signal in occipital horns of bilateral lateral ventricles were increased. In addition, the brain enhanced nuclear magnetic resonance (NMR) scanning suggested that meninges were thickened and enhanced at the base of the brain, with meningitis changes. The neck CT angiography (CTA) revealed arteriosclerotic changes. The metagenomic next-generation sequencing (mNGS) revealed Eubacterium brachy, Porphyromonas gingivalis, Fusobacterium nucleatum and Torque teno virus in her cerebrospinal fluid (CSF). The patient was diagnosed with purulent meningitis caused by infection of oral anaerobes, and treated with mannitol, ceftriaxone and vancomycin. Her symptoms alleviated. Subsequently, she was transferred to the infectious department and treated with ceftriaxone plus metronidazole (anti-anaerobes) and mannitol (reduce intracranial pressure). Her symptoms improved and currently received rehabilitation treatment.", + "summary_subclaims": [ + "A 58-year-old woman was admitted to hospital with fever, headache for 21 days and left limb weakness for 2 days.", + "The blood cell counts were 11.73 × 109/L.", + "The neutrophil counts were 9.22 × 109/L.", + "The high-sensitivity C-reactive protein levels were > 5.00 mg/L.", + "The brain computerized tomography (CT) scanning indicated the new right thalamus infarct.", + "The brain cranial-enhanced magnetic resonance imaging (MRI) showed the right lateral paraventricular and right thalamic infarct.", + "The brain enhanced nuclear magnetic resonance (NMR) scanning suggested that meninges were thickened and enhanced at the base of the brain.", + "The metagenomic next-generation sequencing (mNGS) revealed Eubacterium brachy in her cerebrospinal fluid (CSF).", + "The patient was diagnosed with purulent meningitis caused by infection of oral anaerobes.", + "The patient was treated with ceftriaxone and vancomycin.", + "The patient was transferred to the infectious department.", + "The patient was treated with ceftriaxone plus metronidazole.", + "The patient was treated with mannitol.", + "The patient's symptoms improved." + ] + }, + { + "id": "multiclinsum_test_229_en.txt", + "fulltext": "Here, we present the case of a 59-year-old woman who developed a rapid onset dementia with salient frontal executive dysfunction beginning in February 2016. One month earlier, she had shown prodromal symptoms with a decreased energy level, increased rumination, sleep disturbances, and a loss of appetite with weight loss. No psychoactive causes were identified. In February 2016, she showed rapid worsening of symptoms with increasing loss of interest in daily activities, withdrawal from other people, and reduced spontaneous speech output. Over the next few days, she developed a stuporous state with catatonic features; she lost all personal initiative and moved rarely, her movements appeared to be frozen, she stopped speaking, and she stared blankly. Since then, she has no longer been able to communicate adequately. Verbal exchanges were reduced to answers to questions using one or two words and dramatically prolonged response latencies. Pharmacological treatment with various antidepressants (citalopram up to 20 mg/day, venlafaxine up to 150 mg/day), neuroleptics (amisulpride up to 400 mg/day, aripiprazole up to 15 mg/day, flupentixol up to 1.5 mg/day, quetiapine up to 200 mg/day, risperidone up to 4 mg/day), anxiolytics (lorazepam up to 5 mg/day), and methylprednisolone (5 mg × 500 mg for five consecutive days for presumed SREAT) were administered over the course of more than 6 months, until September 2016. However, all these approaches were unsuccessful. Steroid treatment led to worsening apathy and cognitive slowing. Therefore, the patient was continuously treated in an inpatient setting.\nUpon admission to our clinic (September 2016), she was still in a stuporous state and her perception, concentration, attention, and working memory were severely disturbed. She was aware of her state but negated emotional involvement. Mental fluency and judgment were compromised. She had no energy and was apathetic. However, hallucinations and delusional symptoms were not reported. The neurological examination showed evidence of primitive reflexes (orbicularis oris reflex) and a significantly disturbed Luria’s three-step test. In addition, the patient reported a new micturition disorder.\nThis patient’s developmental history was negative for in utero or birth complications, febrile convulsions, inflammatory brain diseases, and cerebral contusions. There was no evidence of any neurodevelopmental or personality disorders. The premorbid personality was described as vivacious, cheerful, and outgoing. She smoked but did not consume alcohol or illegal drugs. Until the onset of the symptoms at age 58, she was mentally healthy. Her somatic medical history included only complex regional pain syndrome of the right upper extremity (in 2005) and Hashimoto thyroiditis. Her family history of neuropsychiatric or malignant diseases was unremarkable.\nThis patient’s serum anti-TPO and anti-TG antibodies were increased; however, no antineuronal antibodies against intracellular antigens were found. The CSF analyses showed normal findings; antibodies against neuronal cell surface antigens and markers of dementia were negative. A screening for rheumatological autoantibodies was negative. The cMRI showed multiple lesions in deep and peripheral white matter whithout diffusion restriction or contrast enhancement, while intermittent slow activity was detected in the EEG . [18F]fluorodeoxyglucose positron emission tomography (FDG-PET) showed mild-to-moderate medial and superior dorsolateral frontal hypometabolism, which did not allow a clear distinction between early-stage frontotemporal lobar degeneration and secondary non-specific changes (e.g., due to reduced consciousness/apathy, atrophy). An additional [123I]FP-CIT-SPECT revealed a normal striatal dopamine transporter availability . Neuropsychological test batteries for dementia, following the Consortium to Establish a Registry for Alzheimer’s Disease (CERAD), showed deficits in verbal fluency, word list memory, constructional praxis, and trailmaking A/B . The Behavioral Assessment of the Dysexecutive Syndrome (BADS) showed severe impairment (sum-score: 6; average: 16–20; range: 0–24). More complex tasks, like the zoo map test and the modified six elements test, were nonexecutable, as the patient did not understand the instructions.\nThe dysexecutive syndrome (e.g., loss of motivation and ability to judge), cognitive deficits (e.g., working memory deficits), neurological signs (orbicularis oris reflex, Luria’s three-step test), new urinary incontinence, neuropsychological testing, and frontal hypometabolism on FDG-PET were all compatible with a behavioral variant of frontotemporal dementia (FTD). However, the initial clinical course with rapid deterioration within days to weeks was highly unusual for neurodegenerative pathology like FTD; and the trailmaking tests A/B and verbal fluency (in the CERAD) would be adversely affected by the patient’s prevailing conscious state. Therefore, the patient’s conscious state might have influenced the comparability of the serial neuropsychological assessments. However, the cooperation was comparable at the three times of investigation. Alternatively, immunological encephalopathy seemed to be plausible regarding the rapid onset, increased antithyroid antibodies, EEG slowing, white matter lesions, and secondary non-specific FDG-PET alterations. Furthermore, an idiopathic depressive stupor could not be completely ruled out; however, the combination of slowed EEG and frontal FDG-PET hypometabolism is atypical for this differential diagnosis.\nFor optimal antidepressant treatment, lithium therapy was started in September 2016 (450–675 mg/d, serum levels: 0.39–0.69 mmol/l, reference: 0.4–0.8 mmol/l). There was only a questionable minor response to this treatment attempt over a period of 7 weeks. In parallel, we discussed options for immunosuppressive treatment strategies. Although high-dose steroid therapy aggravated symptoms, we started off-label treatment with plasmapheresis (five sessions at the beginning of November 2016) 7 weeks after the initiation of lithium as a last-resort therapeutic attempt. At this time point, the patient’s hypothyroidism was adequately substituted with 0.075 mg/d l-thyroxine.\nA few days after the initiation of plasmapheresis, all the patient’s symptoms improved significantly. Although her oral fluency was still reduced, normal communication was again possible. Her mood improved, her cognitive deficits were reduced, the orbicularis oris reflex disappeared, and the Luria’s three-step test normalized. However, her energy level improved only slightly. This patient was discharged from our clinic in December 2016 (6 weeks after undergoing plasmapheresis) and lived with her husband as before. Her energy levels and micturition disorder gradually improved; however, while her oral fluency and planning skills were enhanced, she still showed slight impairment 6 months after plasmapheresis. The improvement was neuropsychologically documented . One month after plasmapheresis, the patient improved in almost all the initially impaired categories of the CERAD testing battery ; however, the BADS only improved slightly and remained significantly below average (sum score only increased from 6 to 8). Nearly 6 months after undergoing plasmapheresis, the CERAD and BADS (sum score of 8 points) findings were still stable. However, the verbal fluency was slightly reduced. Treatment with lithium (675 mg/d) and l-thyroxine (0.075 mg/d) continued unchanged. The follow-up FDG-PET showed normalization in July 2017 (i.e., the frontal hypometabolism was no longer detectable; Figure ).", + "fulltext_subclaims": [ + "The patient is a 59-year-old woman.", + "She developed a rapid onset dementia with salient frontal executive dysfunction beginning in February 2016.", + "One month before February 2016, she had prodromal symptoms with decreased energy, increased rumination, sleep disturbances, and weight loss.", + "No psychoactive causes were identified.", + "In February 2016, she showed rapid worsening of symptoms with increasing loss of interest in daily activities, withdrawal from other people, and reduced spontaneous speech output.", + "Over the next few days, she developed a stuporous state with catatonic features.", + "She lost all personal initiative and moved rarely.", + "Her movements appeared to be frozen.", + "She stopped speaking and stared blankly.", + "Since then, she has no longer been able to communicate adequately.", + "Verbal exchanges were reduced to answers to questions using one or two words.", + "Response latencies were dramatically prolonged.", + "Pharmacological treatment with various antidepressants, neuroleptics, anxiolytics, and methylprednisolone were administered over the course of more than 6 months, until September 2016.", + "All these approaches were unsuccessful.", + "Steroid treatment led to worsening apathy and cognitive slowing.", + "The patient was continuously treated in an inpatient setting.", + "Upon admission to the clinic in September 2016, she was still in a stuporous state.", + "Her perception, concentration, attention, and working memory were severely disturbed.", + "She was aware of her state but negated emotional involvement.", + "Mental fluency and judgment were compromised.", + "She had no energy and was apathetic.", + "Hallucinations and delusional symptoms were not reported.", + "The neurological examination showed evidence of primitive reflexes (orbicularis oris reflex).", + "The neurological examination showed a significantly disturbed Luria’s three-step test.", + "The patient reported a new micturition disorder.", + "The patient’s developmental history was negative for in utero or birth complications, febrile convulsions, inflammatory brain diseases, and cerebral contusions.", + "There was no evidence of any neurodevelopmental or personality disorders.", + "The premorbid personality was described as vivacious, cheerful, and outgoing.", + "She smoked but did not consume alcohol or illegal drugs.", + "Until the onset of symptoms at age 58, she was mentally healthy.", + "Her somatic medical history included complex regional pain syndrome of the right upper extremity (in 2005) and Hashimoto thyroiditis.", + "Her family history of neuropsychiatric or malignant diseases was unremarkable.", + "The patient’s serum anti-TPO and anti-TG antibodies were increased.", + "No antineuronal antibodies against intracellular antigens were found.", + "CSF analyses showed normal findings.", + "Antibodies against neuronal cell surface antigens and markers of dementia were negative.", + "A screening for rheumatological autoantibodies was negative.", + "The cMRI showed multiple lesions in deep and peripheral white matter without diffusion restriction or contrast enhancement.", + "Intermittent slow activity was detected in the EEG.", + "FDG-PET showed mild-to-moderate medial and superior dorsolateral frontal hypometabolism.", + "The FDG-PET findings did not allow a clear distinction between early-stage frontotemporal lobar degeneration and secondary non-specific changes.", + "An additional [123I]FP-CIT-SPECT revealed a normal striatal dopamine transporter availability.", + "Neuropsychological test batteries showed deficits in verbal fluency, word list memory, constructional praxis, and trailmaking A/B.", + "The BADS showed severe impairment (sum-score: 6; average: 16–20; range: 0–24).", + "More complex tasks, like the zoo map test and the modified six elements test, were nonexecutable.", + "The dysexecutive syndrome, cognitive deficits, neurological signs, new urinary incontinence, neuropsychological testing, and frontal hypometabolism on FDG-PET were all compatible with a behavioral variant of frontotemporal dementia.", + "The initial clinical course with rapid deterioration within days to weeks was highly unusual for neurodegenerative pathology like FTD.", + "The trailmaking tests A/B and verbal fluency would be adversely affected by the patient’s prevailing conscious state.", + "The patient’s conscious state might have influenced the comparability of the serial neuropsychological assessments.", + "The cooperation was comparable at the three times of investigation.", + "Immunological encephalopathy seemed to be plausible regarding the rapid onset, increased antithyroid antibodies, EEG slowing, white matter lesions, and secondary non-specific FDG-PET alterations.", + "An idiopathic depressive stupor could not be completely ruled out.", + "The combination of slowed EEG and frontal FDG-PET hypometabolism is atypical for idiopathic depressive stupor.", + "Lithium therapy was started in September 2016.", + "There was only a questionable minor response to lithium therapy over a period of 7 weeks.", + "Options for immunosuppressive treatment strategies were discussed.", + "High-dose steroid therapy aggravated symptoms.", + "Plasmapheresis was started as a last-resort therapeutic attempt.", + "Plasmapheresis was started 7 weeks after the initiation of lithium.", + "The patient’s hypothyroidism was adequately substituted with 0.075 mg/d l-thyroxine.", + "A few days after the initiation of plasmapheresis, all the patient’s symptoms improved significantly.", + "Normal communication was again possible.", + "Her mood improved, cognitive deficits were reduced, the orbicularis oris reflex disappeared, and the Luria’s three-step test normalized.", + "Her energy level improved only slightly.", + "The patient was discharged from the clinic in December 2016.", + "Her energy levels and micturition disorder gradually improved.", + "Her oral fluency and planning skills were enhanced.", + "She still showed slight impairment 6 months after plasmapheresis.", + "The improvement was neuropsychologically documented.", + "One month after plasmapheresis, the patient improved in almost all the initially impaired categories of the CERAD testing battery.", + "The BADS only improved slightly and remained significantly below average.", + "Nearly 6 months after plasmapheresis, the CERAD and BADS findings were still stable.", + "Verbal fluency was slightly reduced.", + "Treatment with lithium and l-thyroxine continued unchanged.", + "The follow-up FDG-PET showed normalization in July 2017." + ], + "summary": "Here, we present the case of a 59-year-old female patient suffering rapid onset dementia with salient frontal executive dysfunction. She developed rapid onset symptoms, including apathy, verbal depletion up to a stuporous state, severe working memory deficits, evidence of primitive reflexes, disturbed Luria's three-step test, and micturition disorder. Analysis of her cerebrospinal fluid was normal. The serum analyses showed increased antithyroid (antithyroid peroxidase and antithyroglobulin) antibodies. In the cerebral magnetic resonance imaging, supratentorial deep and peripheral white matter lesions were found; the electroencephalography showed intermittent slowing, and the", + "summary_subclaims": [ + "The patient is a 59-year-old female.", + "The patient suffered rapid onset dementia.", + "The patient had salient frontal executive dysfunction.", + "The patient developed apathy.", + "The patient had verbal depletion up to a stuporous state.", + "The patient had severe working memory deficits.", + "There was evidence of primitive reflexes.", + "There was a disturbed Luria's three-step test.", + "The patient had micturition disorder.", + "Cerebrospinal fluid analysis was normal.", + "Serum analyses showed increased antithyroid peroxidase antibodies.", + "Serum analyses showed increased antithyroglobulin antibodies.", + "Cerebral magnetic resonance imaging showed supratentorial deep and peripheral white matter lesions.", + "Electroencephalography showed intermittent slowing." + ] + }, + { + "id": "multiclinsum_test_1148_en.txt", + "fulltext": "A 53-year-old woman was admitted to The First Hospital of Jilin University in September 2019 because of right axillary metastatic carcinoma.\nThe patient presented with an enlarged lymph node in her right axillary area 2 wk before she visited a local hospital for examination. A needle puncture biopsy of the lymph node indicated right axillary metastatic carcinoma, most likely originating from mammary tissue.\nShe had no previous history of any illnesses.\nThe patient had no relevant personal or family history.\nPhysical examination indicated no lumps in the breasts. A hard, fused and fixed lump 6.0 cm × 3.0 cm in size was identified in her right axillary area.\nThere was no abnormality.\nUS revealed a hypoechoic mass 6.0 cm × 3.2 cm × 2.0 cm in size in the right axilla, which had internal vascularity. Breast lesions were not identified by US, mammography or magnetic resonance imaging . There was no evidence of a malignant primary lesion or distant metastasis on computed tomography scans of the thorax, abdomen and bone. Immunohistochemical staining results were positive for progesterone receptor (PR), cytokeratin (CK) 7 and specific breast markers GATA3 and gross cystic disease fluid protein-15. Tumor cells were negative for estrogen receptor (ER), human epidermal growth factor receptor-2 (HER-2), CK5/6, CK20 and villin.", + "fulltext_subclaims": [ + "A 53-year-old woman was admitted to The First Hospital of Jilin University in September 2019 because of right axillary metastatic carcinoma.", + "The patient presented with an enlarged lymph node in her right axillary area 2 wk before she visited a local hospital for examination.", + "A needle puncture biopsy of the lymph node indicated right axillary metastatic carcinoma, most likely originating from mammary tissue.", + "She had no previous history of any illnesses.", + "The patient had no relevant personal or family history.", + "Physical examination indicated no lumps in the breasts.", + "A hard, fused and fixed lump 6.0 cm × 3.0 cm in size was identified in her right axillary area.", + "There was no abnormality.", + "US revealed a hypoechoic mass 6.0 cm × 3.2 cm × 2.0 cm in size in the right axilla, which had internal vascularity.", + "Breast lesions were not identified by US, mammography or magnetic resonance imaging.", + "There was no evidence of a malignant primary lesion or distant metastasis on computed tomography scans of the thorax, abdomen and bone.", + "Immunohistochemical staining results were positive for progesterone receptor (PR), cytokeratin (CK) 7 and specific breast markers GATA3 and gross cystic disease fluid protein-15.", + "Tumor cells were negative for estrogen receptor (ER), human epidermal growth factor receptor-2 (HER-2), CK5/6, CK20 and villin." + ], + "summary": "A 53-year-old woman presented with a lump in her right axillary area with no primary lesions in the breast. Pathological biopsy confirmed right axillary metastatic carcinoma. Immunohistochemical staining results were positive for progesterone receptor, cytokeratin 7, specific breast markers GATA3 and gross cystic disease fluid protein-15. Tumor cells were negative for estrogen receptor, human epidermal growth factor receptor-2, cytokeratin 5/6, cytokeratin 20, and villin. The patient was diagnosed with OBC, and she underwent neoadjuvant chemotherapy combined with anlotinib. Mastectomy plus axillary lymph node dissection was performed. The patient achieved pathologic complete response with no residual invasive tumor cells in the breast or axillary lymph nodes. Postoperatively, she received adjuvant radiotherapy and endocrine therapy.", + "summary_subclaims": [ + "A 53-year-old woman presented with a lump in her right axillary area.", + "There were no primary lesions in the breast.", + "Pathological biopsy confirmed right axillary metastatic carcinoma.", + "Immunohistochemical staining results were positive for progesterone receptor.", + "Immunohistochemical staining results were positive for cytokeratin 7.", + "Immunohistochemical staining results were positive for GATA3.", + "Immunohistochemical staining results were positive for gross cystic disease fluid protein-15.", + "Tumor cells were negative for estrogen receptor.", + "Tumor cells were negative for human epidermal growth factor receptor-2.", + "Tumor cells were negative for cytokeratin 5/6.", + "Tumor cells were negative for cytokeratin 20.", + "Tumor cells were negative for villin.", + "The patient was diagnosed with OBC.", + "The patient underwent neoadjuvant chemotherapy combined with anlotinib.", + "Mastectomy plus axillary lymph node dissection was performed.", + "The patient achieved pathologic complete response.", + "There were no residual invasive tumor cells in the breast.", + "There were no residual invasive tumor cells in the axillary lymph nodes.", + "Postoperatively, she received adjuvant radiotherapy.", + "Postoperatively, she received endocrine therapy." + ] + }, + { + "id": "multiclinsum_test_34_en.txt", + "fulltext": "Rectal bleeding.\nA 79-year-old male who presented with rectal bleeding and discovery of large thrombosed internal hemorrhoids during screening colonoscopy. He reported intermittent hematochezia and denied rectal pain or changes in the frequency, consistency or caliber of bowel movements. He is a self-reported never smoker who adheres to a high-fiber diet. The patient subsequently underwent an uneventful three-column hemorrhoidectomy. The internal hemorrhoids were identified, excised, and sent for routine pathologic evaluation. Pathologic analysis revealed the left lateral hemorrhoid column positive for a 1.5 cm moderate-to-poorly differentiated adenocarcinoma. The tumor showed superficial invasion into the submucosa along with a focus that was suspicious for lymphatic invasion .\nThe patient has a history of atrial fibrillation, diabetes, and remote history of hemorrhoids. The patient underwent a previous laser ablation 10 years prior for bleeding internal hemorrhoids. However, there was no procedure note to denote the location of the bleeding hemorrhoid or pathology report to suggest biopsy in the electronic medical record.\nDigital rectal examination prior to hemorrhoidectomy revealed one small skin tag, but was otherwise unremarkable. He had no inguinal lymphadenopathy. Anoscopy revealed a single large inflamed and prolapsing internal hemorrhoid.\nHemoglobin A1c (HbA1c), 6.3%; and albumin, 4.4 g/dL.\nComputed tomography (CT) chest/abdomen/pelvis-negative, endorectal ultrasound-negative.", + "fulltext_subclaims": [ + "The patient is a 79-year-old male.", + "The patient presented with rectal bleeding.", + "Large thrombosed internal hemorrhoids were discovered during screening colonoscopy.", + "The patient reported intermittent hematochezia.", + "The patient denied rectal pain.", + "The patient denied changes in the frequency of bowel movements.", + "The patient denied changes in the consistency of bowel movements.", + "The patient denied changes in the caliber of bowel movements.", + "The patient is a self-reported never smoker.", + "The patient adheres to a high-fiber diet.", + "The patient underwent an uneventful three-column hemorrhoidectomy.", + "The internal hemorrhoids were identified.", + "The internal hemorrhoids were excised.", + "The excised hemorrhoids were sent for routine pathologic evaluation.", + "Pathologic analysis revealed the left lateral hemorrhoid column positive for a 1.5 cm moderate-to-poorly differentiated adenocarcinoma.", + "The tumor showed superficial invasion into the submucosa.", + "The tumor had a focus suspicious for lymphatic invasion.", + "The patient has a history of atrial fibrillation.", + "The patient has a history of diabetes.", + "The patient has a remote history of hemorrhoids.", + "The patient underwent a previous laser ablation 10 years prior for bleeding internal hemorrhoids.", + "There was no procedure note to denote the location of the bleeding hemorrhoid.", + "There was no pathology report to suggest biopsy in the electronic medical record.", + "Digital rectal examination prior to hemorrhoidectomy revealed one small skin tag.", + "Digital rectal examination prior to hemorrhoidectomy was otherwise unremarkable.", + "The patient had no inguinal lymphadenopathy.", + "Anoscopy revealed a single large inflamed and prolapsing internal hemorrhoid.", + "Hemoglobin A1c (HbA1c) was 6.3%.", + "Albumin was 4.4 g/dL.", + "Computed tomography (CT) chest/abdomen/pelvis was negative.", + "Endorectal ultrasound was negative." + ], + "summary": "The patient was a 79-year-old male who presented with rectal bleeding and was found to have large thrombosed internal hemorrhoids during screening colonoscopy. The patient subsequently underwent a three-column hemorrhoi-dectomy. Pathologic analysis revealed one of three specimens containing a 1.5 cm moderate-to-poorly differentiated adenocarcinoma of anal origin with superficial submucosal invasion. At three-month follow up, he was taken to the operating theatre for biopsy and re-excision of his non-healing wound, which showed no recurrence. His wound has since healed and he was cancer free at ten-month follow up.", + "summary_subclaims": [ + "The patient was a 79-year-old male.", + "The patient presented with rectal bleeding.", + "The patient was found to have large thrombosed internal hemorrhoids during screening colonoscopy.", + "The patient underwent a three-column hemorrhoidectomy.", + "Pathologic analysis revealed one of three specimens containing a 1.5 cm moderate-to-poorly differentiated adenocarcinoma of anal origin.", + "The adenocarcinoma had superficial submucosal invasion.", + "At three-month follow up, the patient was taken to the operating theatre for biopsy and re-excision of his non-healing wound.", + "The biopsy and re-excision showed no recurrence.", + "The wound has since healed.", + "The patient was cancer free at ten-month follow up." + ] + }, + { + "id": "multiclinsum_test_703_en.txt", + "fulltext": "A fifty-five-year-old man with hypertension and who used regular medications for anxiety came to the Emergency Room in Malmö, Sweden, complaining of dyspnea in 2009. He had arrived to Sweden by plane from Sri Lanka five days prior, where he resides a large part of the year. Upon exiting Sri Lanka, he was put into custody for almost 6 weeks under unhygienic conditions.\nAlready in Sri Lanka, but aggravated upon the return to Sweden, the patient experienced throat pain and shortness of breath. At the emergency room the patient presented with severe shortness of breath and fever of 39 °C. Throat inspection revealed swelling and greyish membranes. The patient deteriorated quickly with hypoxia and hypercapnia. He was intubated and put under ventilator support. Bronchoscopy showed greyish membranous plaques covering the larger part of the bronchus and partly occluding the left major bronchus. Serial X-rays showed progressive atelectasis of the left lung . The membranes could mechanically be removed from its underlying layer and repeated bronchoscopies with lavage were performed.\nCulture specimens were sent from larynx and bronchoscopy specimens as well as from a 1 cm2 skin ulceration. Due to suspicion of diphtheria, Loeffler’s tellurite media was used for culture. On day four from admission, the results from cultures showed growth of toxin producing C. diphtheriae, subsequently typed to non-gravis, both from the ulcer and from the respiratory tract. Serologies for Human Immunodeficiency Virus (HIV), hepatitis B and C and syphilis returned negative, as well as urine antigen tests for Streptococcus pneumoniae and Legionella pneumophila. The diphtheria strain was susceptible to both cefotaxime and erythromycin, which the patient was receiving since admission. It was in this situation judged too late for administration of DAT in relation to possible side effects and the duration of symptoms, and the patient was never administered this treatment. In the following weeks (day 5–14), the patient showed signs of improvement in infection control with decreasing C-reactive protein (CRP) and was afebrile, however the left lung remained deflated. The patient was under ventilator support for one month through tracheostomy performed on day seven. The prolonged time in ventilator was due to inability to recruit the left lung, despite repeated bronchoscopy and cleaning of greyish debris from the airways. A pleural catheter was also placed in the left inter pleural space with clearance of about one liter of transudative fluid. Bacterial cultures from the pleural fluid were negative.\nBetween day 14 and 16 the patient had changes in the electrocardiogram with T-wave inversions and short periods of ventricular tachycardia as well as elevated cardiac enzymes that resolved spontaneously . An echocardiogram was performed with no significant pathology. Additionally, a passing increase in serum creatinine was noted during this period. No clear reasons for these adverse organ effects were identified and were judged to be Diphtheria toxin related. On day 19 the patient deteriorated with fever and increased purulent secretions from the airways. This was considered due to Ventilator Associated Pneumonia (VAP) with Methicillin Resistant Staphylococcus aureus (MRSA) which was successfully treated with intravenous vancomycin for two weeks. In the fourth week, the patient improved and could gradually be weaned off of the ventilator. The tracheostomy tube was removed on day 46 from admission and the patient was mobilized in the following week with physical therapy and was prepared to be discharged to a center for rehabilitation.\nOn day 55, however, the patient developed a gradual onset of neurological symptoms. First he got increasingly weaker voice and shortly thereafter weakness of the extremities, and increasing difficulties to breathe. From day 58, the patient quickly deteriorated with a complete paraplegia and respiratory failure ensued, requiring reintubation. Repeated neurographic examinations showed severe polyneuropathy with mixed demyelination and axonal loss. The pattern was not deemed to be consistent with Guillain-Barré, nor Critical Illness and was judged to be due to toxin effects of diphtheria toxin thus no neuroimaging was considered necessary. Furthermore, lumbar puncture showed no significant pathology.\nOn day 56, surveillance Bronchiole Alveolar Lavage (BAL)-culture was sent for extensive testing and culture due to respiratory deterioration. This subsequently showed growth of Mycobacterium tuberculosis (MTB) fully sensitive to rifampicin, isoniazide, pyrazinamide and ethambutol. MTB-PCR was negative. Bronchoscopy specimens for MTB culture and PCR had previously been sent for investigation on day two from admission, but was negative at that time. The patient was started on combination therapy for pulmonary tuberculosis (TB) on day 70.\nThe patient gradually regained motor function from day 80 and the patient could once again be weaned off of the ventilator. The sensory functions likewise gradually returned from the center to the periphery . After an extended stay for mobilization, the patient was discharged to a rehabilitation clinic on day 91 from admission. On follow up after three and six months, the patient continued to improve in motor and sensory functions, The patient was followed for three years reporting only minor polyneuropathic symptoms in his feet, but had resumed his daily activities with no motor impairments.", + "fulltext_subclaims": [ + "The patient is a fifty-five-year-old man.", + "He has hypertension.", + "He used regular medications for anxiety.", + "He came to the Emergency Room in Malmö, Sweden, complaining of dyspnea in 2009.", + "He had arrived to Sweden by plane from Sri Lanka five days prior.", + "He resides a large part of the year in Sri Lanka.", + "Upon exiting Sri Lanka, he was put into custody for almost 6 weeks under unhygienic conditions.", + "He experienced throat pain and shortness of breath already in Sri Lanka.", + "The symptoms were aggravated upon the return to Sweden.", + "At the emergency room, the patient presented with severe shortness of breath.", + "At the emergency room, the patient presented with fever of 39 °C.", + "Throat inspection revealed swelling and greyish membranes.", + "The patient deteriorated quickly with hypoxia and hypercapnia.", + "He was intubated and put under ventilator support.", + "Bronchoscopy showed greyish membranous plaques covering the larger part of the bronchus.", + "Bronchoscopy showed greyish membranous plaques partly occluding the left major bronchus.", + "Serial X-rays showed progressive atelectasis of the left lung.", + "The membranes could mechanically be removed from its underlying layer.", + "Repeated bronchoscopies with lavage were performed.", + "Culture specimens were sent from larynx and bronchoscopy specimens.", + "Culture specimens were sent from a 1 cm2 skin ulceration.", + "Due to suspicion of diphtheria, Loeffler’s tellurite media was used for culture.", + "On day four from admission, the results from cultures showed growth of toxin producing C. diphtheriae.", + "The diphtheria strain was typed to non-gravis.", + "The diphtheria strain was isolated from the ulcer.", + "The diphtheria strain was isolated from the respiratory tract.", + "Serologies for HIV, hepatitis B and C, and syphilis returned negative.", + "Urine antigen tests for Streptococcus pneumoniae and Legionella pneumophila returned negative.", + "The diphtheria strain was susceptible to cefotaxime.", + "The diphtheria strain was susceptible to erythromycin.", + "The patient was receiving cefotaxime since admission.", + "The patient was receiving erythromycin since admission.", + "It was judged too late for administration of DAT in relation to possible side effects.", + "The patient was never administered DAT.", + "In the following weeks (day 5–14), the patient showed signs of improvement in infection control.", + "CRP decreased in the following weeks.", + "The patient was afebrile in the following weeks.", + "The left lung remained deflated.", + "The patient was under ventilator support for one month.", + "A tracheostomy was performed on day seven.", + "The prolonged time in ventilator was due to inability to recruit the left lung.", + "A pleural catheter was placed in the left inter pleural space.", + "About one liter of transudative fluid was cleared from the left inter pleural space.", + "Bacterial cultures from the pleural fluid were negative.", + "Between day 14 and 16, the patient had changes in the electrocardiogram with T-wave inversions.", + "Between day 14 and 16, the patient had short periods of ventricular tachycardia.", + "Between day 14 and 16, the patient had elevated cardiac enzymes.", + "The cardiac enzyme elevations resolved spontaneously.", + "An echocardiogram was performed with no significant pathology.", + "A passing increase in serum creatinine was noted during this period.", + "No clear reasons for these adverse organ effects were identified.", + "The adverse organ effects were judged to be Diphtheria toxin related.", + "On day 19, the patient deteriorated with fever.", + "On day 19, the patient had increased purulent secretions from the airways.", + "This was considered due to Ventilator Associated Pneumonia (VAP) with MRSA.", + "This was successfully treated with intravenous vancomycin for two weeks.", + "In the fourth week, the patient improved.", + "The patient could gradually be weaned off of the ventilator.", + "The tracheostomy tube was removed on day 46 from admission.", + "The patient was mobilized in the following week with physical therapy.", + "The patient was prepared to be discharged to a center for rehabilitation.", + "On day 55, the patient developed a gradual onset of neurological symptoms.", + "First he got increasingly weaker voice.", + "Shortly thereafter, he had weakness of the extremities.", + "He had increasing difficulties to breathe.", + "From day 58, the patient quickly deteriorated with a complete paraplegia.", + "Respiratory failure ensued, requiring reintubation.", + "Repeated neurographic examinations showed severe polyneuropathy with mixed demyelination and axonal loss.", + "The pattern was not deemed to be consistent with Guillain-Barré.", + "The pattern was not deemed to be consistent with Critical Illness.", + "The polyneuropathy was judged to be due to toxin effects of diphtheria toxin.", + "No neuroimaging was considered necessary.", + "Lumbar puncture showed no significant pathology.", + "On day 56, surveillance BAL-culture was sent for extensive testing and culture.", + "This showed growth of Mycobacterium tuberculosis (MTB) fully sensitive to rifampicin.", + "This showed growth of Mycobacterium tuberculosis (MTB) fully sensitive to isoniazide.", + "This showed growth of Mycobacterium tuberculosis (MTB) fully sensitive to pyrazinamide.", + "This showed growth of Mycobacterium tuberculosis (MTB) fully sensitive to ethambutol.", + "MTB-PCR was negative.", + "Bronchoscopy specimens for MTB culture and PCR had previously been sent on day two from admission.", + "The MTB culture and PCR on day two from admission were negative.", + "The patient was started on combination therapy for pulmonary tuberculosis (TB) on day 70.", + "The patient gradually regained motor function from day 80.", + "The patient could once again be weaned off of the ventilator.", + "Sensory functions gradually returned from the center to the periphery.", + "The patient was discharged to a rehabilitation clinic on day 91 from admission.", + "On follow up after three and six months, the patient continued to improve in motor and sensory functions.", + "The patient was followed for three years.", + "The patient reported only minor polyneuropathic symptoms in his feet.", + "The patient had resumed his daily activities with no motor impairments." + ], + "summary": "A 55-year old male presented to the emergency room with severe respiratory symptoms and greyish membranes in the airways, which turned positive for C. diphtheriae. He was put on ventilator support and remained hospitalized for three months. During care he developed myocarditis and severe neurological disease and he was also co-infected with tuberculosis. The patient was discharged with a favorable outcome.", + "summary_subclaims": [ + "A 55-year old male presented to the emergency room with severe respiratory symptoms and greyish membranes in the airways.", + "The greyish membranes turned positive for C. diphtheriae.", + "He was put on ventilator support.", + "He remained hospitalized for three months.", + "During care he developed myocarditis.", + "During care he developed severe neurological disease.", + "He was co-infected with tuberculosis.", + "The patient was discharged with a favorable outcome." + ] + }, + { + "id": "multiclinsum_test_2963_en.txt", + "fulltext": "A 22-year-old female was referred to our out-patient clinic for follow-up on her asymptomatic mitral valve prolapse (MVP), which was discovered incidentally when she was 6 years old. She had never previously experienced dyspnea, chest pain or syncope. Physical examination revealed a grade 3/6 systolic murmur at the upper left sternal border. Her electrocardiogram showed sinus rhythm with left anterior fascicular block and T wave inversion in leads I and aVL. All laboratory tests, including cardiac troponin, N-terminal pro-B-type natriuretic peptide (NT-pro BNP) and autoantibodies, were unremarkable.\nIn addition to the anterior mitral leaflet prolapse (A2) with moderate mitral regurgitation and a mildly dilated left ventricle (left ventricular end-diastolic diameter: 56 mm) with a preserved ejection fraction , transthoracic echocardiogram revealed a retrograde blood flow from an extremely dilated left coronary artery (LCA) . Coronary angiography also revealed an enormously dilated and tortuous right coronary artery (RCA) originating from the right coronary cusp, with many collateral vessels filling the LCA (Additional file: Video 3), but failed to locate the orifice of LCA. Further coronary computed tomography angiography confirmed the diagnosis of ALCAPA .\nGiven her high risk of left ventricular dysfunction, heart failure and malignant ventricular dysrhythmias, surgical correction was scheduled. Intraoperatively, her coronary arteries were found to be extremely dilated, the left ventricle and mitral annulus were mildly dilated, and anterior mitral leaflet appeared apparently thickened with rolled edges. More importantly, a chordae tendineae connecting the anterior leaflet (A2) was ruptured and markedly shortened . Therefore, reimplantation of the LCA into the aorta and concomitant mitral valve replacement were performed. The patient recovered uneventfully and was discharged from the hospital 2 weeks later. Three months following surgery, an echocardiogram revealed that her left ventricle had returned to normal (left ventricular end-diastolic diameter: 47 mm).", + "fulltext_subclaims": [ + "The patient is a 22-year-old female.", + "She was referred to the out-patient clinic for follow-up on her asymptomatic mitral valve prolapse.", + "The mitral valve prolapse was discovered incidentally when she was 6 years old.", + "She had never previously experienced dyspnea.", + "She had never previously experienced chest pain.", + "She had never previously experienced syncope.", + "Physical examination revealed a grade 3/6 systolic murmur at the upper left sternal border.", + "Her electrocardiogram showed sinus rhythm.", + "Her electrocardiogram showed left anterior fascicular block.", + "Her electrocardiogram showed T wave inversion in leads I and aVL.", + "All laboratory tests were unremarkable.", + "Transthoracic echocardiogram revealed anterior mitral leaflet prolapse (A2) with moderate mitral regurgitation.", + "Transthoracic echocardiogram revealed a mildly dilated left ventricle.", + "The left ventricular end-diastolic diameter was 56 mm.", + "Transthoracic echocardiogram revealed a preserved ejection fraction.", + "Transthoracic echocardiogram revealed retrograde blood flow from an extremely dilated left coronary artery.", + "Coronary angiography revealed an enormously dilated and tortuous right coronary artery.", + "Coronary angiography showed many collateral vessels filling the left coronary artery.", + "Coronary computed tomography angiography confirmed the diagnosis of ALCAPA.", + "Surgical correction was scheduled.", + "Intraoperatively, the coronary arteries were found to be extremely dilated.", + "The left ventricle and mitral annulus were mildly dilated.", + "The anterior mitral leaflet appeared apparently thickened with rolled edges.", + "A chordae tendineae connecting the anterior leaflet (A2) was ruptured and markedly shortened.", + "Reimplantation of the left coronary artery into the aorta was performed.", + "Concomitant mitral valve replacement was performed.", + "The patient was discharged from the hospital 2 weeks after surgery.", + "Three months following surgery, an echocardiogram revealed that her left ventricle had returned to normal.", + "The left ventricular end-diastolic diameter was 47 mm three months after surgery." + ], + "summary": "A 22-year-old female presented with a 16-year history of anterior mitral leaflet prolapse. However, she had never experienced any discomfort before. At a routine follow-up, a transthoracic echocardiogram showed anterior mitral leaflet prolapse (A2) with moderate mitral regurgitation, and a retrograde blood flow from an extremely dilated left coronary artery (LCA). Further coronary angiography and coronary computed tomography angiography confirmed the diagnosis of ALCAPA. She subsequently underwent successful LCA reimplantation and concomitant mitral valve replacement. Intraoperatively, her mitral annulus was mildly dilated, anterior mitral valve leaflet appeared markedly thickened with rolled edges, and a chordae tendineae connecting the anterior leaflet (A2) was ruptured and markedly shortened.", + "summary_subclaims": [ + "The patient is a 22-year-old female.", + "She had a 16-year history of anterior mitral leaflet prolapse.", + "She had never experienced any discomfort before.", + "A transthoracic echocardiogram showed anterior mitral leaflet prolapse (A2) with moderate mitral regurgitation.", + "A retrograde blood flow from an extremely dilated left coronary artery (LCA) was observed.", + "Coronary angiography and coronary computed tomography angiography confirmed the diagnosis of ALCAPA.", + "She underwent successful LCA reimplantation.", + "She underwent concomitant mitral valve replacement.", + "Intraoperatively, her mitral annulus was mildly dilated.", + "The anterior mitral valve leaflet appeared markedly thickened with rolled edges.", + "A chordae tendineae connecting the anterior leaflet (A2) was ruptured and markedly shortened." + ] + }, + { + "id": "multiclinsum_test_2180_en.txt", + "fulltext": "A 25-year-old male presented to our department with two episodes of gross hematuria. Personal and family medical history were negative of any underlying diseases. Ultrasound revealed lobulated paracalyceal cystic – like lesions in the parenchyma of the right kidney with no dilation of its pelvicalyceal system .\nContrast enhanced computed tomography in the arterial phase demonstrated dilated upper lobe interlobar artery of the right kidney and early enhancement of a variceal venous structure which drained in the right renal vein, findings indicative of renal arteriovenous fistula . There was no history of trauma or medical procedure, so the RAVF was considered as non -traumatic. Fistulous site was measured approximately 12 mm.\nThe procedure was conducted in the cath lab (Siemens Artis Zee) under aseptic conditions and local anesthesia. Patient was in supine position and vital signs were monitored throughout the procedure. Under ultrasound guidance puncture of the right common femoral artery was performed and a 5F vascular sheath was introduced. A pre – shaped 5F Cobra catheter (Merit Medical) was advanced. Then, a 6 F × 45 cm Ansel guiding sheath (Cook Medical) was advanced into the proximal right renal artery. DSA revealed an enlarged interlobar renal artery and early opacification of an enlarged draining vein and inferior vena cava (IVC), findings indicative of type I RAVF .\nNext, under ultrasound guidance, puncture of the right common femoral vein was performed and a 5F vascular sheath was introduced. A pre—shaped 5F Simmons catheter (Merit Medical) was advanced into the right renal vein and selective catheterization of the dilated vein was performed with the help of a hydrophilic guidewire (Terumo). Super – selective catheterization of the venous pouch adjacent to the feeding artery was achieved by a 2,7F microcatheter (Progreat, Terumo).\nThen, a Hyperform 7 × 15 mm balloon (Medtronic) was advanced into the feeding artery across the site of the fistula. Selective angiogram with the balloon inflated showed no opacification of the fistula and the accurate site of the communication was documented and type I RAVF was confirmed. A 2,6 F microcatheter (Asahi Intecc) was advanced at the venous pouch at the site of the fistula and multiple electrically detachable metallic coils (Optima/OptiMAX/BALT) were simultaneously deployed through the transarterial and transvenous microcatheter into the fistula initially with the balloon inflated . In particular, there were used three coils 18 × 20 mm, one 14 × 47 mm, one 13 × 43 mm, one 12 × 40 mm, two 10 × 30 mm, one 10 × 17 mm and one 10 × 13 mm. Balloon inflation prevents coil migration and protrusion of the coils into the feeding artery.\nThe final result was total occlusion of the fistula with preservation of feeding artery and the renal parenchyma .\nThere were no minor or major complications. Patient was discharged the following day in good condition, with the instruction of a new contrast enhanced computed tomography after 6 months.", + "fulltext_subclaims": [ + "A 25-year-old male presented to our department with two episodes of gross hematuria.", + "Personal and family medical history were negative of any underlying diseases.", + "Ultrasound revealed lobulated paracalyceal cystic-like lesions in the parenchyma of the right kidney.", + "Contrast enhanced computed tomography in the arterial phase demonstrated dilated upper lobe interlobar artery of the right kidney.", + "Contrast enhanced computed tomography in the arterial phase demonstrated early enhancement of a variceal venous structure which drained in the right renal vein.", + "The findings were indicative of renal arteriovenous fistula.", + "There was no history of trauma or medical procedure.", + "The RAVF was considered as non-traumatic.", + "The fistulous site was measured approximately 12 mm.", + "The procedure was conducted in the cath lab (Siemens Artis Zee) under aseptic conditions and local anesthesia.", + "The patient was in supine position.", + "Vital signs were monitored throughout the procedure.", + "Under ultrasound guidance puncture of the right common femoral artery was performed.", + "A 5F vascular sheath was introduced.", + "A pre-shaped 5F Cobra catheter (Merit Medical) was advanced.", + "A 6 F × 45 cm Ansel guiding sheath (Cook Medical) was advanced into the proximal right renal artery.", + "DSA revealed an enlarged interlobar renal artery.", + "DSA revealed early opacification of an enlarged draining vein and inferior vena cava (IVC).", + "The findings were indicative of type I RAVF.", + "Under ultrasound guidance, puncture of the right common femoral vein was performed.", + "A 5F vascular sheath was introduced.", + "A pre—shaped 5F Simmons catheter (Merit Medical) was advanced into the right renal vein.", + "Selective catheterization of the dilated vein was performed with the help of a hydrophilic guidewire (Terumo).", + "Super-selective catheterization of the venous pouch adjacent to the feeding artery was achieved by a 2,7F microcatheter (Progreat, Terumo).", + "A Hyperform 7 × 15 mm balloon (Medtronic) was advanced into the feeding artery across the site of the fistula.", + "Selective angiogram with the balloon inflated showed no opacification of the fistula.", + "The accurate site of the communication was documented.", + "Type I RAVF was confirmed.", + "A 2,6 F microcatheter (Asahi Intecc) was advanced at the venous pouch at the site of the fistula.", + "Multiple electrically detachable metallic coils (Optima/OptiMAX/BALT) were simultaneously deployed through the transarterial and transvenous microcatheter into the fistula initially with the balloon inflated.", + "There were used three coils 18 × 20 mm, one 14 × 47 mm, one 13 × 43 mm, one 12 × 40 mm, two 10 × 30 mm, one 10 × 17 mm and one 10 × 13 mm.", + "Balloon inflation prevents coil migration and protrusion of the coils into the feeding artery.", + "The final result was total occlusion of the fistula with preservation of feeding artery and the renal parenchyma.", + "There were no minor or major complications.", + "The patient was discharged the following day in good condition.", + "The patient was instructed to have a new contrast enhanced computed tomography after 6 months." + ], + "summary": "We present a case of successful balloon - assisted coil embolization of a high flow renal arteriovenous fistula in a 25-year-old male patient via simultaneous transarterial and transvenous approach with preservation of the feeding artery.", + "summary_subclaims": [ + "We present a case of successful balloon - assisted coil embolization of a high flow renal arteriovenous fistula.", + "The patient was a 25-year-old male.", + "The procedure was performed via simultaneous transarterial and transvenous approach.", + "The feeding artery was preserved." + ] + }, + { + "id": "multiclinsum_test_1591_en.txt", + "fulltext": "Our patient was a 20-year-old Arabic Middle Eastern woman. She was not known to have any medical illness. She had had two previous uneventful pregnancies with uncomplicated vaginal deliveries. Her only antenatal visit to our hospital was at 38 weeks of gestation, when she presented in early labor. Her general physical examination was unremarkable. An ultrasound (US) scan showed a cephalic, normally grown fetus with decreased amniotic fluid. The patient’s whole blood platelet count was 182 × 109/L, white blood cell count (WBC) was 11 × 109/L, and whole blood hemoglobin (Hb) was 116 g/L. Her blood group was AB positive.\nOn vaginal examination, she was found to have a 3-cm dilated, 80% effaced cervix and intact membranes. She was augmented with artificial rupture of her membranes and syntocinon intravenous infusion. Six hours later, she had an uneventful vaginal delivery of a healthy male newborn weighing 3.06 kg. The baby’s Apgar scores at 1 and 5 minutes were 8 and 9, respectively.\nOn the morning of her first postpartum day, the patient complained of a nonpruritic maculopapular skin rash over her upper limbs , abdomen , and back. It appeared suddenly as patchy lesions. It was not associated with pustules or vesicles. Her neck, face, and the palmar aspects of her hands and lower limbs were spared. There were no noticeable striae over her abdomen. She was not known to have any allergic reactions, and she did not receive any medications that could explain the findings. Twelve hours later, she was feeling very unwell and tired. She then developed generalized abdominal pain that increased in severity and was associated with nausea and occasional vomiting. Her vital signs were normal (blood pressure [BP] 120/70 mmHg, pulse rate 83 beats/minute, and oral temperature 37.1 °C). Her urine was yellow and turbid with 3+ proteinuria, and she had numerous WBC/high-power field (HPF) but no glycosuria. The same result was confirmed by testing a second urine sample that was obtained via a Foley catheter. A dermatologist’s review indicated nonspecific maculopapular skin rash, and the dermatologist advised only observation with no specific therapy but to investigate further. This advice alerted the medical staff to do further testing, which showed that her liver function, kidney function, whole blood count, serum glucose, serum lactate dehydrogenase (LDH), and coagulation profile were within normal limits.\nDay 2 postpartum was marked by persistence of nausea and vomiting and a decrease in the intensity of skin rash. On day 3 postpartum, she had nausea, vomiting, and abdominal pain. Her skin rash showed a further decrease in intensity. She was very sick, pale, and jaundiced with epigastric and right upper quadrant abdominal tenderness. Her vital signs were stable. Investigations were repeated and showed thrombocytopenia (platelet count 54 × 109/L), hypoglycemia (serum glucose 2.11 mmol/L), renal impairment (serum creatinine 228.75 μmol/L), impaired liver function (serum alanine aminotransferase [ALT] 0.735 μkat/L, serum aspartate aminotransferase [AST] 1.15 μkat/L, serum LDH 19.8 μkat/L, serum total bilirubin 68.4 μmol/L, serum direct bilirubin 58.15 μmol/L), and coagulopathy (plasma prothrombin time [PT] 22 seconds, control 14 seconds, blood partial thromboplastin time [PTT] 36 seconds, control 26 seconds, international normalized ratio [INR] 1.85) with normal urinalysis and normal plasma d-dimer and fibrin degradation products.\nAcute fatty liver was suspected, and the patient was admitted to the ICU in the evening. In the ICU, her blood Hb was 88 g/L (dropped from 105 g/L), and her blood platelet count was 51 × 109/L. Internist, hematologist, and anesthetist consultants were involved in her care. Septic workup was done, including urine and blood cultures, as well as high vaginal and endocervical swabs for culture and sensitivity. Because she was critically ill in the ICU with too many intravenous catheters and an indwelling urinary catheter, and because patients with AFLP are at risk of infection, a decision was taken by the multidisciplinary team to start her on a renal dose of imipenem/cilastatin. She was kept on intravenous fluid, normal saline (N/S) 100 ml/hour, and dextrose infusion. Five units of fresh frozen plasma (FFP), 5 U of cryoprecipitate, and 2 U of packed red blood cells (PRBCs) were given.\nOn the fourth day postpartum, the patient had persistent nausea, vomiting, and epigastric and right upper quadrant abdominal pain. Her vital signs were stable. She was jaundiced. Her skin rash had significantly decreased in distribution and intensity. She had a strict fluid input-output observation. Her urine output remained around 45–60 ml/hour. Her investigations showed anemia and thrombocytopenia (blood Hb 79 g/L and blood platelet count 44 × 109/L), acute renal impairment (serum creatinine 316.4 μmol/L), very high serum LDH (19.7 μkat/L), elevated serum ALT (0.77 μkat/L), and elevated serum AST (1.52 μkat/L) with elevated serum direct and total bilirubin. Her serum glucose was 3.38 mmol/L (on dextrose infusion), and her total serum bile acids level was normal (6 μmol/L). Blood film showed hypochromic microcytic anemia, few schistocytes and acanthocytes, neutrophilia with toxic granulation of neutrophils, a majority of neutrophils that were hypersegmented, and thrombocytopenia. She received 2 U of PRBCs, 2 U of FFP, and 4 U of cryoprecipitate and was started on dexamethasone 4 mg intravenously every 8 hours.\nIn the afternoon, after transfusion of blood and blood products, her blood platelet count was 38 × 109/L, blood Hb 97 g/L, and blood WBC 14.9 × 109/L. Other tests revealed plasma PT 17.5 seconds, blood PTT 29.7 seconds, and INR 1.4 (corrected by the infusion of the blood and blood products).\nAn abdominopelvic computed tomographic (CT) scan without contrast enhancement revealed only hyperdense free fluid (ascites). A chest x-ray (CXR) showed congestive pulmonary changes and blunted bilateral costophrenic angles. She was started on furosemide 20 mg intravenously every 4 hours, intravenous fluid dextrose 25% 50 ml/hour, and N/S 0.9% 50 ml/hour.\nOn the fifth day postpartum (the third day in the ICU), the patient still felt unwell with epigastric and right upper quadrant abdominal pain and recurrent attacks of hypoglycemia. She had no skin rash at all. She had normal BP readings with mild epigastric and right upper quadrant tenderness. Her laboratory tests showed anemia, thrombocytopenia, hypoglycemia, leukocytosis, renal impairment, hyperbilirubinemia, and elevated serum LDH. Urinalysis showed 1+ proteinuria and hematuria. The result of a viral hepatitis screen was negative.\nAn abdominal U/S scan showed a marked amount of free fluid in the abdomen, liver span 17 cm, spleen span 14 cm, and a normal hepatobiliary tree with no stones or dilatation. A CXR was normal. She was given 5 U of FFP and kept on the antibiotic because of the ascitic fluid.\nOn the sixth day postpartum (fourth day in the ICU), the patient showed significant clinical improvement with stable vital signs (V/S). Her blood tests showed persistent anemia, thrombocytopenia, leukocytosis, elevated serum creatinine, elevated serum LDH, mild elevation of serum bilirubin, normal serum glucose, and normal liver enzymes and coagulation. A repeat blood film showed hypochromic microcytic anemia with mild anisocytosis, neutrophilic leukocytosis, few hypersegmented neutrophils and thrombocytopenia with large forms. She was prophylactically given 5 U of FFP as suggested by the multidisciplinary team.\nOn the seventh day postpartum (fifth day in the ICU), the patient started to show much clinical improvement (very mild nausea, occasional vomiting, and mild abdominal pain) with stable V/S. Blood tests showed Hb 98 g/L, blood platelet count 60 × 109/L, blood WBC 16 × 109/L (76% neutrophils and 16% lymphocytes), serum glucose 6.1 mmol/L, serum creatinine 251.6 μmol/L, serum urea nitrogen 52.1 mmol/L, and serum LDH 11.6 μkat/L with normal electrolytes and liver enzymes.\nA CXR showed reticular shadowing bilaterally, a blunt left costophrenic angle, and a clear right costophrenic angle, which further supported the continuation of the antibiotic. She was given 4 U of FFP.\nOn the eighth day postpartum (the sixth day in the ICU), the patient was very well with no nausea, vomiting, or abdominal pain. Her dextrose infusion was disconnected. She was started on oral intake of fluids. She remained normoglycemic. She was prophylactically given 5 U of cryoprecipitate, 5 U of FFP, and 2 U of PRBCs for of her mild thrombocytopenia and anemia. In the evening, repeat blood test results were normal apart from mild elevation of serum creatinine. A decision was taken to discharge her from the ICU.\nOn the ninth day postpartum (the first day in the obstetric ward), the patient was very well with no complaints. She resumed breastfeeding in addition to artificial supplement. Her laboratory test results were normal. Her full septic workup result was negative. Imipenem/cilastatin was discontinued.\nOn the tenth day postpartum, the patient was very well and had no complaint. The results of her blood tests were normal apart from very mildly elevated serum creatinine.\nThe patient’s 11th postpartum day was unremarkable; she had no complaints and normal laboratory test results.\nOn the 12th day postpartum (4th day in the obstetric ward), the patient was very well with stable vital signs and no complaints. She had normal serum glucose, normal serum electrolytes, and normal liver enzymes and serum bilirubin (total and direct). Her serum LDH was 10.1 μkat/L, blood Hb 105 g/L, blood platelet count 584 × 109/L, blood WBC 11.6 × 106/L, and serum creatinine 1.43. In the afternoon, she was discharged to home receiving no medications.\nThe patient was seen in the clinic 1 week later. She was doing well with no complaints and was seeking contraception.\nOne month later, she and her baby were doing well with no complaints. In the clinic, she had an intrauterine contraceptive device inserted. The chronological order of her symptomatology and laboratory results are shown in Tables and , respectively.", + "fulltext_subclaims": [ + "The patient was a 20-year-old Arabic Middle Eastern woman.", + "She was not known to have any medical illness.", + "She had had two previous uneventful pregnancies with uncomplicated vaginal deliveries.", + "Her only antenatal visit to our hospital was at 38 weeks of gestation.", + "An ultrasound scan showed a cephalic, normally grown fetus with decreased amniotic fluid.", + "The patient’s whole blood platelet count was 182 × 109/L.", + "Her blood group was AB positive.", + "On vaginal examination, she was found to have a 3-cm dilated, 80% effaced cervix and intact membranes.", + "She was augmented with artificial rupture of her membranes and syntocinon intravenous infusion.", + "Six hours later, she had an uneventful vaginal delivery of a healthy male newborn weighing 3.06 kg.", + "The baby’s Apgar scores at 1 and 5 minutes were 8 and 9, respectively.", + "On the morning of her first postpartum day, the patient complained of a nonpruritic maculopapular skin rash over her upper limbs, abdomen, and back.", + "It was not associated with pustules or vesicles.", + "Her neck, face, and the palmar aspects of her hands and lower limbs were spared.", + "She was not known to have any allergic reactions.", + "She did not receive any medications that could explain the findings.", + "A dermatologist’s review indicated nonspecific maculopapular skin rash.", + "The dermatologist advised only observation with no specific therapy.", + "This advice alerted the medical staff to do further testing.", + "Day 2 postpartum was marked by persistence of nausea and vomiting.", + "Her skin rash showed a further decrease in intensity.", + "On day 3 postpartum, she had nausea, vomiting, and abdominal pain.", + "Her skin rash showed a further decrease in intensity.", + "She was very sick, pale, and jaundiced with epigastric and right upper quadrant abdominal tenderness.", + "Investigations showed thrombocytopenia (platelet count 54 × 109/L).", + "Investigations showed hypoglycemia (serum glucose 2.11 mmol/L).", + "Investigations showed renal impairment (serum creatinine 228.75 μmol/L).", + "Investigations showed impaired liver function (serum ALT 0.735 μkat/L, serum AST 1.15 μkat/L, serum LDH 19.8 μkat/L, serum total bilirubin 68.4 μmol/L, serum direct bilirubin 58.15 μmol/L).", + "Investigations showed coagulopathy (plasma prothrombin time 22 seconds, control 14 seconds, blood partial thromboplastin time 36 seconds, control 26 seconds, international normalized ratio 1.85).", + "Acute fatty liver was suspected.", + "The patient was admitted to the ICU in the evening.", + "In the ICU, her blood Hb was 88 g/L.", + "In the ICU, her blood platelet count was 51 × 109/L.", + "Internist, hematologist, and anesthetist consultants were involved in her care.", + "A decision was taken by the multidisciplinary team to start her on a renal dose of imipenem/cilastatin.", + "She was kept on intravenous fluid, normal saline 100 ml/hour, and dextrose infusion.", + "Five units of fresh frozen plasma, 5 U of cryoprecipitate, and 2 U of packed red blood cells were given.", + "On the fourth day postpartum, the patient had persistent nausea, vomiting, and epigastric and right upper quadrant abdominal pain.", + "Her investigations showed anemia and thrombocytopenia (blood Hb 79 g/L and blood platelet count 44 × 109/L).", + "Her investigations showed acute renal impairment (serum creatinine 316.4 μmol/L).", + "Her investigations showed very high serum LDH (19.7 μkat/L).", + "Her investigations showed elevated serum ALT (0.77 μkat/L) and elevated serum AST (1.52 μkat/L).", + "Her serum glucose was 3.38 mmol/L.", + "Blood film showed hypochromic microcytic anemia.", + "Blood film showed few schistocytes and acanthocytes.", + "Blood film showed neutrophilia with toxic granulation of neutrophils.", + "Blood film showed a majority of neutrophils that were hypersegmented.", + "Blood film showed thrombocytopenia.", + "She received 2 U of PRBCs, 2 U of FFP, and 4 U of cryoprecipitate.", + "She was started on dexamethasone 4 mg intravenously every 8 hours.", + "An abdominopelvic computed tomographic scan without contrast enhancement revealed only hyperdense free fluid (ascites).", + "A chest x-ray showed congestive pulmonary changes and blunted bilateral costophrenic angles.", + "She was started on furosemide 20 mg intravenously every 4 hours.", + "On the fifth day postpartum, the patient still felt unwell with epigastric and right upper quadrant abdominal pain.", + "She had no skin rash at all.", + "Her laboratory tests showed anemia, thrombocytopenia, hypoglycemia, leukocytosis, renal impairment, hyperbilirubinemia, and elevated serum LDH.", + "The result of a viral hepatitis screen was negative.", + "An abdominal ultrasound scan showed a marked amount of free fluid in the abdomen.", + "An abdominal ultrasound scan showed liver span 17 cm.", + "An abdominal ultrasound scan showed spleen span 14 cm.", + "An abdominal ultrasound scan showed a normal hepatobiliary tree with no stones or dilatation.", + "A chest x-ray was normal.", + "She was given 5 U of FFP.", + "On the sixth day postpartum, the patient showed significant clinical improvement with stable vital signs.", + "Her blood tests showed persistent anemia, thrombocytopenia, leukocytosis, elevated serum creatinine, elevated serum LDH, mild elevation of serum bilirubin, normal serum glucose, and normal liver enzymes and coagulation.", + "A repeat blood film showed hypochromic microcytic anemia with mild anisocytosis.", + "A repeat blood film showed neutrophilic leukocytosis.", + "A repeat blood film showed few hypersegmented neutrophils and thrombocytopenia with large forms.", + "She was prophylactically given 5 U of FFP.", + "On the seventh day postpartum, the patient started to show much clinical improvement with stable vital signs.", + "Blood tests showed Hb 98 g/L.", + "Blood tests showed blood platelet count 60 × 109/L.", + "Blood tests showed blood WBC 16 × 109/L.", + "Blood tests showed serum glucose 6.1 mmol/L.", + "Blood tests showed serum creatinine 251.6 μmol/L.", + "Blood tests showed serum urea nitrogen 52.1 mmol/L.", + "Blood tests showed serum LDH 11.6 μkat/L.", + "A chest x-ray showed reticular shadowing bilaterally.", + "A chest x-ray showed a blunt left costophrenic angle.", + "A chest x-ray showed a clear right costophrenic angle.", + "She was given 4 U of FFP.", + "On the eighth day postpartum, the patient was very well with no nausea, vomiting, or abdominal pain.", + "Her dextrose infusion was disconnected.", + "She was started on oral intake of fluids.", + "She remained normoglycemic.", + "She was prophylactically given 5 U of cryoprecipitate, 5 U of FFP, and 2 U of PRBCs.", + "In the evening, repeat blood test results were normal apart from mild elevation of serum creatinine.", + "A decision was taken to discharge her from the ICU.", + "On the ninth day postpartum, the patient was very well with no complaints.", + "She resumed breastfeeding in addition to artificial supplement.", + "Her laboratory test results were normal.", + "Her full septic workup result was negative.", + "Imipenem/cilastatin was discontinued.", + "On the tenth day postpartum, the patient was very well and had no complaint.", + "The results of her blood tests were normal apart from very mildly elevated serum creatinine.", + "The patient’s 11th postpartum day was unremarkable.", + "She had no complaints and normal laboratory test results.", + "On the 12th day postpartum, the patient was very well with stable vital signs and no complaints.", + "She had normal serum glucose, normal serum electrolytes, and normal liver enzymes and serum bilirubin.", + "Her serum LDH was 10.1 μkat/L.", + "Her blood Hb was 105 g/L.", + "Her blood platelet count was 584 × 109/L.", + "Her blood WBC was 11.6 × 106/L.", + "Her serum creatinine was 1.43.", + "In the afternoon, she was discharged to home receiving no medications.", + "The patient was seen in the clinic 1 week later.", + "She was doing well with no complaints.", + "She was seeking contraception.", + "One month later, she and her baby were doing well with no complaints.", + "In the clinic, she had an intrauterine contraceptive device inserted." + ], + "summary": "We report a case of a 20-year-old Middle Eastern Arabic woman who developed an acute fatty liver of pregnancy. She was not known to have any medical disease. She had had two previous uncomplicated deliveries. She developed acute fatty liver of pregnancy on the first day after an uncomplicated normal vaginal delivery of a healthy male newborn. She started to have nonitchy skin rash over her abdomen and upper limbs. Then she started to feel unwell. Twelve hours later, she developed epigastric and right upper quadrant abdominal pain, followed by jaundice, nausea, and vomiting. She developed recurrent hypoglycemic attacks, hemolytic anemia, coagulopathy, and hepatorenal syndrome.", + "summary_subclaims": [ + "The patient is a 20-year-old Middle Eastern Arabic woman.", + "She developed acute fatty liver of pregnancy.", + "She was not known to have any medical disease.", + "She had had two previous uncomplicated deliveries.", + "She developed acute fatty liver of pregnancy on the first day after an uncomplicated normal vaginal delivery of a healthy male newborn.", + "She started to have nonitchy skin rash over her abdomen and upper limbs.", + "She started to feel unwell.", + "Twelve hours later, she developed epigastric and right upper quadrant abdominal pain.", + "She developed jaundice.", + "She had nausea and vomiting.", + "She developed recurrent hypoglycemic attacks.", + "She developed hemolytic anemia.", + "She developed coagulopathy.", + "She developed hepatorenal syndrome." + ] + }, + { + "id": "multiclinsum_test_1525_en.txt", + "fulltext": "A 22-year-old Sri Lankan man presented with acute onset diplopia, progressively worsening over one week. He had noted that his eyelids were drooping, especially towards end of the day. He did not experience dysphagia, dysarthria or limb weakness. He had been diagnosed with end stage renal failure (ESRF) due to obstructive uropathy one year ago. Although his serum creatinine had been 16.4 mg/dl (normal: 0.7 – 1.3) five months ago, he had not consented for renal replacement therapy.\nOn examination, he had a fatigable bilateral asymmetrical partial ptosis (additional file 1) and a positive curtain sign (manually raising the more ptotic lid causes increased ptosis on the opposite side), but the Cogan’s lid twitch and peek signs were negative. There was a complex external ophthalmoplegia without nystagmus . The pupils were normal. Limb power was 5/5 (modified medical research council score) in all four limbs, no cerebellar signs were noted and the sensation to pin prick and joint position sense was intact. The rest of the examination were normal apart from severe pallor. The blood pressure was 130/80 mmHg. The bedside ice-pack test for ocular myasthenia gravis was negative.\nThe biochemical parameters on admission are given in the Table .\nAfter correcting the hypocalcaemia, haemodialysis was commenced because of the severe acidosis and continued on an alternate day frequency.\nIn the evaluation for the cause of the patient’s complex ophthalmoplegia and fatigable ptosis, the following investigations were done .\nAcetylcholine receptor antibodies were not tested due to resource constraints.\nThe patient’s ophthalmoplegia improved completely by the end of the first week after initiating haemodialysis and the ptosis resolved by the end of the second week . The MRI of the brain repeated after two weeks demonstrated marked improvement in the previously noted brainstem abnormalities with residual mild T2W/FLAIR hyperintensities in the midbrain. T2W hyperintensities in the internal capsule and cerebellar peduncles had completely resolved .", + "fulltext_subclaims": [ + "The patient is a 22-year-old Sri Lankan man.", + "He had acute onset diplopia.", + "The diplopia had been progressively worsening over one week.", + "He noted that his eyelids were drooping, especially towards the end of the day.", + "He did not experience dysphagia.", + "He did not experience dysarthria.", + "He did not experience limb weakness.", + "He had been diagnosed with end stage renal failure due to obstructive uropathy one year ago.", + "His serum creatinine had been 16.4 mg/dl five months ago.", + "He had not consented for renal replacement therapy.", + "On examination, he had a fatigable bilateral asymmetrical partial ptosis.", + "The Cogan’s lid twitch and peek signs were negative.", + "There was a complex external ophthalmoplegia without nystagmus.", + "The pupils were normal.", + "Limb power was 5/5 in all four limbs.", + "The bedside ice-pack test for ocular myasthenia gravis was negative.", + "Acetylcholine receptor antibodies were not tested due to resource constraints.", + "The patient’s ophthalmoplegia improved completely by the end of the first week after initiating haemodialysis.", + "The ptosis resolved by the end of the second week.", + "The MRI of the brain repeated after two weeks demonstrated marked improvement in the previously noted brainstem abnormalities.", + "T2W hyperintensities in the internal capsule and cerebellar peduncles had completely resolved." + ], + "summary": "A 22-year-old Sri Lankan man with end stage renal failure presented with acute onset diplopia and drooping of eyelids progressively worsening over one week. The patient had not complied with the prescribed renal replacement therapy which was planned to be initiated 5 months previously. On examination, his Glasgow coma scale score was 15/15, He had a fatigable asymmetrical bilateral ptosis. The ice-pack test was negative. There was a complex ophthalmoplegia with bilateral abduction failure and elevation failure of the right eye. The diplopia did not worsen with prolonged stare. The rest of the neurological examination was normal. Serum creatinine on admission was 21.81 mg/dl. The repetitive nerve stimulation did not show a decremental pattern. Magnetic resonance imaging (MRI) of the brain demonstrated diffuse midbrain and pontine oedema with T2 weighted/FLAIR hyperintensities. The patient was haemodialyzed on alternate days and his neurological deficits completely resolved by the end of the second week of dialysis. The follow up brain MRI done two weeks later demonstrated marked improvement of the brainstem oedema with residual T2 weighted/FLAIR hyperintensities in the midbrain.", + "summary_subclaims": [ + "The patient is a 22-year-old Sri Lankan man.", + "The patient had end stage renal failure.", + "He presented with acute onset diplopia.", + "He had drooping of eyelids progressively worsening over one week.", + "The patient had not complied with the prescribed renal replacement therapy.", + "The renal replacement therapy was planned to be initiated 5 months previously.", + "On examination, his Glasgow coma scale score was 15/15.", + "He had a fatigable asymmetrical bilateral ptosis.", + "The ice-pack test was negative.", + "There was a complex ophthalmoplegia with bilateral abduction failure.", + "There was elevation failure of the right eye.", + "The diplopia did not worsen with prolonged stare.", + "The rest of the neurological examination was normal.", + "Serum creatinine on admission was 21.81 mg/dl.", + "The repetitive nerve stimulation did not show a decremental pattern.", + "MRI of the brain demonstrated diffuse midbrain and pontine oedema.", + "The MRI showed T2 weighted/FLAIR hyperintensities.", + "The patient was haemodialyzed on alternate days.", + "His neurological deficits completely resolved by the end of the second week of dialysis.", + "The follow up brain MRI demonstrated marked improvement of the brainstem oedema.", + "There were residual T2 weighted/FLAIR hyperintensities in the midbrain." + ] + }, + { + "id": "multiclinsum_test_1131_en.txt", + "fulltext": "A 67-year-old male subject with severe hemithorax pain and dyspnea, along with disseminated pain and muscle weakness in the right shoulder and down the arm, was referred to our institution. Pulmonary evaluation revealed coarse as well as dull breathing sounds. Laboratory data showed normocytic normochromic anemia, whereas white blood cells, platelets, liver and renal functions, calcium, phosphorus and alkaline phosphatase (ALP) were all within normal levels and there were no signs of organomegaly or lymphadenopathy. The chest x-ray showed collapse of the right upper lobe. The patient was further evaluated for suspected bronchogenic cancer with brachial plexus involvement. Histopathological analysis showed poorly differentiated squamous cell carcinoma.\nCT of the chest, upper abdomen and brain was performed with contrast and revealed some pulmonary nodules with hilar mass, resorptive atelectasis and obstructive pneumonia, along with destruction of the adjacent rib vertebra and extension to the spinal canal; there were no signs of brain involvement . MRI on the chest also demonstrated destruction of vertebrae and invasion into the spinal canal, thereby compressing the spinal cord . MRI on the spine confirmed the presence of a lytic lesion in the T4 vertebral body .\nThree hours after administration of 750 MBq (20 mCi) technetium-99m methylene diphosphonate (Tc-99m MDP) by injection, WBBS was performed using a rotating digital gamma camera (ADAC Pegasys) equipped with a low-energy all-purpose parallel whole collimator, with a 20% window centered at 140 keV to provide energy discrimination. SPECT images were obtained in a 128 × 128 matrix, in 64 steps, with 40 s per step. The images were reconstructed and displayed on all three axes: vertical long axis, horizontal long axis and axial short axis. We found an area of diminished radiotracer uptake in the T3-T5 vertebrae and in the posterior arch of the third to fifth right ribs .\nThe patient was further evaluated for induction chemoradiotherapy and was subsequently subjected to a palliative en-bloc surgical operation with a posterior approach .", + "fulltext_subclaims": [ + "The patient is a 67-year-old male.", + "The patient had severe hemithorax pain.", + "The patient had dyspnea.", + "The patient had disseminated pain.", + "The patient had muscle weakness in the right shoulder.", + "The patient had muscle weakness down the right arm.", + "Pulmonary evaluation revealed coarse breathing sounds.", + "Pulmonary evaluation revealed dull breathing sounds.", + "Laboratory data showed normocytic normochromic anemia.", + "White blood cells were within normal levels.", + "Platelets were within normal levels.", + "Liver functions were within normal levels.", + "Renal functions were within normal levels.", + "Calcium was within normal levels.", + "Phosphorus was within normal levels.", + "Alkaline phosphatase was within normal levels.", + "There were no signs of organomegaly.", + "There were no signs of lymphadenopathy.", + "The chest x-ray showed collapse of the right upper lobe.", + "The patient was evaluated for suspected bronchogenic cancer.", + "The patient was evaluated for brachial plexus involvement.", + "Histopathological analysis showed poorly differentiated squamous cell carcinoma.", + "CT of the chest, upper abdomen, and brain was performed with contrast.", + "CT revealed some pulmonary nodules.", + "CT revealed a hilar mass.", + "CT revealed resorptive atelectasis.", + "CT revealed obstructive pneumonia.", + "CT revealed destruction of the adjacent rib vertebra.", + "CT revealed extension to the spinal canal.", + "There were no signs of brain involvement.", + "MRI on the chest demonstrated destruction of vertebrae.", + "MRI on the chest demonstrated invasion into the spinal canal.", + "MRI on the chest showed compression of the spinal cord.", + "MRI on the spine confirmed the presence of a lytic lesion in the T4 vertebral body.", + "WBBS was performed three hours after administration of 750 MBq Tc-99m MDP.", + "WBBS was performed using a rotating digital gamma camera.", + "SPECT images were obtained in a 128 × 128 matrix.", + "SPECT images were obtained in 64 steps.", + "SPECT images were reconstructed and displayed on all three axes.", + "An area of diminished radiotracer uptake was found in the T3-T5 vertebrae.", + "An area of diminished radiotracer uptake was found in the posterior arch of the third to fifth right ribs.", + "The patient was evaluated for induction chemoradiotherapy.", + "The patient was subjected to a palliative en-bloc surgical operation.", + "The surgical operation used a posterior approach." + ], + "summary": "We describe a case of Pancoast tumor in which technetium-99m methylene diphosphonate (Tc-99m MDP) bone single-photon emission-computed tomography (SPECT) was able to accurately detect multiple areas of abnormality in the vertebrae and ribs. In describing this case, we stress the clinical and diagnostic points, in the hope of stimulating a higher degree of suspicion and thereby facilitating appropriate diagnosis and treatment. From the results of this study, further clinical trials to evaluate the potential of SPECT as an efficient imaging tool for the work-up on cases of Pancoast tumor are recommended.", + "summary_subclaims": [ + "We describe a case of Pancoast tumor.", + "Technetium-99m methylene diphosphonate (Tc-99m MDP) bone single-photon emission-computed tomography (SPECT) was able to accurately detect multiple areas of abnormality in the vertebrae and ribs.", + "In describing this case, we stress the clinical and diagnostic points.", + "From the results of this study, further clinical trials to evaluate the potential of SPECT as an efficient imaging tool for the work-up on cases of Pancoast tumor are recommended." + ] + }, + { + "id": "multiclinsum_test_1588_en.txt", + "fulltext": "A 78-year-old male with chronic kidney disease, dementia and sequelae of cerebral hemorrhage presented to his family doctor complaining of back pain; however, there were no abnormal findings on physical examination. Three days later, the back pain worsened and an ambulance was called. When the ambulance crew (including an emergency doctor) arrived at his home, his systolic blood pressure was 50 mm Hg, and the doctor performed portable echocardiography on site. Cardiac tamponade was diagnosed, and pericardiocentesis was performed using a puncture needle via the subxiphoidal approach. After draining ~ 500 ml of bloody pericardial fluid, the patient’s blood pressure immediately increased to 124/98 mm Hg. The patient was transferred to our hospital by helicopter with the outer cannula of the puncture needle placed in the pericardial cavity, and his hemodynamic status was stable at the time of arrival. We immediately started intravenous administration of saline (200 mL/h) to prevent the decrease in blood pressure due to blood loss. Electrocardiogram revealed negative T waves with slight ST elevation in II, III, and aVF leads, and echocardiography revealed severe hypokinesis at the left ventricular inferior wall and a small pericardial effusion. Laboratory tests showed the abnormal values in white blood cell (12.5 × 109/L, reference range, 3.3 to 8.6 × 109/L), C-reactive protein levels (68.5 mg/L, reference range < 1.4 mg/L), creatinine (1.24 mg/dL, reference range, 0.46–0.79 mg/dL), and highly sensitive troponin I (6559 ng/L, reference range < 34.2 ng/L). Creatinine phosphokinase levels (101 IU/L, reference range, 41 to 153 IU/L), hemoglobin (12.3 g/L, reference range, 11.6 to 14.8 g/L), and platelets (254 × 109/L, reference range, 158 to 348 × 109/L) were within reference range. We quickly performed contrast-enhanced computed tomography of the chest. A small protrusion of contrast media was observed on the inferior wall of the left ventricle, suggesting cardiac rupture due to acute myocardial infarction (AMI) . The tip of the outer cannula was confirmed in the pericardial cavity and appeared to reach epicardial adipose tissue around the right ventricle . Emergency coronary angiography was then performed, which confirmed occlusion of the posterior descending branch of the left circumflex coronary artery . Stenotic or occluded lesions were not found in other coronary arteries, and the patient's coronary tree was left side dominant. In addition, extravasation of contrast medium due to Ellis type III coronary artery perforation was observed in the acute marginal branch of the right coronary artery . We considered that coronary artery perforation had occurred as a complication of the pericardial puncture, and we performed transcatheter coil embolization of the perforated branch. A hydrophilic microcatheter (internal diameter, 0.018-in.; MIZUKI standard, KANEKA, Japan) was advanced selectively immediately proximal to the site of leakage in the acute marginal branch. One 0.018-in. and 20-mm-long tapered microcoil (diameter, 2 mm; Hilal, Cook, USA) was quickly released using the microcatheter, and angiography confirmed immediate vessel sealing and hemostasis 170 min after the emergency pericardiocentesis . After the coil embolization, there was no new bloody pericardial effluent and the patient was hemodynamically stable. Therefore, we reduced the rate of intravenous saline administration to 1 mL/kg/h. The total amount of drained bloody pericardial fluid was 610 ml including the first 500 ml. Hemoglobin level decreased to 8.9 g/L, and we performed blood transfusion. The total amount of contrast medium used in contrast-enhanced computed tomography and coronary angiography was 165 ml. Creatinine increased to 1.89 mg/dL 48 h after the use of contrast medium, and the urine volume decreased. Therefore, intravenous administration of saline continued, and then the urine volume gradually increased. Consequently, Intravenous administration of saline had been performed for 7 days. Timeline of clinical presentation and treatment was presented in Table .\nOozing-type cardiac rupture due to AMI was considered as a cause of the cardiac tamponade, but the time of onset of AMI could not be identified, and subsequent blood tests had shown no increase in cardiac enzyme levels. Considering the general condition of the patient, who had dementia and comorbid chronic kidney disease, and the requests of the patient and his family, the patient underwent conservative treatment without cardiac surgery for oozing-type cardiac rupture and any procedure for occlusion of the posterior descending branch of the left circumflex coronary artery. Although the patient made steady progress without a further increase in pericardial effusion after the procedure, the patient needed treatment for a concomitant aspiration pneumonia (from day 3 to day 24 of admission) and rehabilitation for muscle weakness due to protracted bed rest. Finally, the patient was discharged on the 50th day after admission. Creatinine level was 1.28 mg/dL at the time of discharge.", + "fulltext_subclaims": [ + "The patient was a 78-year-old male with chronic kidney disease, dementia, and sequelae of cerebral hemorrhage.", + "He presented to his family doctor complaining of back pain.", + "There were no abnormal findings on physical examination.", + "Three days later, the back pain worsened and an ambulance was called.", + "When the ambulance crew arrived, his systolic blood pressure was 50 mm Hg.", + "The emergency doctor performed portable echocardiography on site.", + "Cardiac tamponade was diagnosed.", + "Pericardiocentesis was performed using a puncture needle via the subxiphoidal approach.", + "After draining ~500 ml of bloody pericardial fluid, the patient’s blood pressure increased to 124/98 mm Hg.", + "The patient was transferred to the hospital by helicopter with the outer cannula of the puncture needle placed in the pericardial cavity.", + "His hemodynamic status was stable at the time of arrival.", + "Intravenous administration of saline (200 mL/h) was started to prevent the decrease in blood pressure due to blood loss.", + "Electrocardiogram revealed negative T waves with slight ST elevation in II, III, and aVF leads.", + "Echocardiography revealed severe hypokinesis at the left ventricular inferior wall.", + "Echocardiography revealed a small pericardial effusion.", + "White blood cell count was 12.5 × 109/L.", + "C-reactive protein levels were 68.5 mg/L.", + "Creatinine was 1.24 mg/dL.", + "Highly sensitive troponin I was 6559 ng/L.", + "Contrast-enhanced computed tomography of the chest showed a small protrusion of contrast media on the inferior wall of the left ventricle.", + "The protrusion suggested cardiac rupture due to acute myocardial infarction.", + "Emergency coronary angiography confirmed occlusion of the posterior descending branch of the left circumflex coronary artery.", + "Extravasation of contrast medium due to Ellis type III coronary artery perforation was observed in the acute marginal branch of the right coronary artery.", + "We considered that coronary artery perforation had occurred as a complication of the pericardial puncture.", + "Transcatheter coil embolization of the perforated branch was performed.", + "A hydrophilic microcatheter was advanced selectively immediately proximal to the site of leakage in the acute marginal branch.", + "One 0.018-in. and 20-mm-long tapered microcoil was quickly released using the microcatheter.", + "Angiography confirmed immediate vessel sealing and hemostasis 170 min after the emergency pericardiocentesis.", + "The total amount of drained bloody pericardial fluid was 610 ml.", + "Hemoglobin level decreased to 8.9 g/L.", + "Blood transfusion was performed.", + "The total amount of contrast medium used was 165 ml.", + "Creatinine increased to 1.89 mg/dL 48 h after the use of contrast medium.", + "The urine volume decreased.", + "Intravenous administration of saline continued.", + "The urine volume gradually increased.", + "Intravenous administration of saline had been performed for 7 days.", + "Oozing-type cardiac rupture due to AMI was considered as a cause of the cardiac tamponade.", + "The time of onset of AMI could not be identified.", + "Subsequent blood tests had shown no increase in cardiac enzyme levels.", + "The patient underwent conservative treatment without cardiac surgery for oozing-type cardiac rupture.", + "The patient needed treatment for a concomitant aspiration pneumonia.", + "The patient was discharged on the 50th day after admission.", + "Creatinine level was 1.28 mg/dL at the time of discharge." + ], + "summary": "A 78-year-old male made an emergency call complaining of the back pain. When the ambulance crew arrived at his home, he was in a state of shock due to cardiac tamponade diagnosed by portable echocardiography. The pericardiocentesis was performed using a puncture needle on site, and the patient was immediately transferred to our hospital by helicopter. Contrast-enhanced computed tomography showed a small protrusion of contrast media on the inferior wall of the left ventricle, suggesting cardiac rupture due to acute myocardial infarction. Emergency coronary angiography was then performed, which confirmed occlusion of the posterior descending branch of the left circumflex coronary artery. In addition, extravasation of contrast medium due to coronary artery perforation was observed in the acute marginal branch of the right coronary artery. We considered that coronary artery perforation had occurred as a complication of the pericardial puncture. We therefore performed transcatheter coil embolization of the perforated branch, and angiography confirmed immediate vessel sealing and hemostasis. After the procedure, the patient made steady progress without a further increase in pericardial effusion, and was discharged on the 50th day after admission.", + "summary_subclaims": [ + "A 78-year-old male made an emergency call complaining of the back pain.", + "When the ambulance crew arrived at his home, he was in a state of shock due to cardiac tamponade diagnosed by portable echocardiography.", + "The pericardiocentesis was performed using a puncture needle on site.", + "The patient was immediately transferred to our hospital by helicopter.", + "Contrast-enhanced computed tomography showed a small protrusion of contrast media on the inferior wall of the left ventricle.", + "The protrusion of contrast media suggested cardiac rupture due to acute myocardial infarction.", + "Emergency coronary angiography was then performed.", + "Emergency coronary angiography confirmed occlusion of the posterior descending branch of the left circumflex coronary artery.", + "Extravasation of contrast medium due to coronary artery perforation was observed in the acute marginal branch of the right coronary artery.", + "We considered that coronary artery perforation had occurred as a complication of the pericardial puncture.", + "We performed transcatheter coil embolization of the perforated branch.", + "Angiography confirmed immediate vessel sealing and hemostasis.", + "After the procedure, the patient made steady progress without a further increase in pericardial effusion.", + "The patient was discharged on the 50th day after admission." + ] + }, + { + "id": "multiclinsum_test_157_en.txt", + "fulltext": "A 70-year-old man presented to the Emergency Department (ED) with 4 days of increasing shortness of breath and fatigue, having a positive SARS-CoV-2 screening test 15 days before. His past medical history included arterial hypertension, rheumatoid arthritis and prostate cancer under radiotherapy and hormone therapy.\nAt ED, he denied fever, chills, chest and abdominal pain, nausea, or vomiting. He had no fever, but was breathless, tachypneic, and severely hypoxemic with a peripheral oxygen saturation of 64% under room air, improving to 98% on 15L of oxygen/minute via a nonrebreather mask. Chest examination revealed bilateral crackles and wheezing. Arterial blood gas analysis showed a respiratory alkalosis and hypoxemia (arterial oxygen partial pressure - PaO2/fractional inspired oxygen - FiO2 ratio 170). Laboratory tests showed an elevated C-reactive protein (43.73 mg/dL) and D-dimer (35 200 ng/mL) and acute kidney injury AKIN 2. The chest X-ray revealed bilateral reticulonodular infiltrates and linear opacities with a predominantly peripheral distribution. COVID-19 pneumonia was diagnosed. He was admitted to the general ward and dexamethasone was promptly started maintaining oxygen via non-rebreather mask, therapeutic-dose anticoagulation, and diuretic therapy. In the first 48h he developed severe respiratory failure and was transferred to the ICU, requiring IMV, after a failed trial of NIV with progressive ascent parameters until Continuous positive airway pressure 12 cmH2O and FiO2 90%, for about 24 hours.\nThe patient remained deeply sedated on pressure-controlled mode ventilation. Due severe respiratory failure, neuromuscular blocking agents were applied during the first 72h, and then by short intermittent infusion or bolus as needed basis to reduce patient-ventilator asynchrony and to access respiratory mechanics. Recruitment manoeuvres were applied once by stepwise approach reaching a peak inspiratory pressure of 35 cmH2O and respecting 15 cmH2O of driving pressure. Then the PEEP was set for the best compliance and low driving pressure. Oxygenation and pulmonary compliance improved without haemodynamic instability. Lung-protective ventilation was maintained with low tidal volume around 6 mL/Kg of predicted body weight, plateau pressure below 30 cmH2O, PEEP of 15 cmH2O and FiO2 of 55%. Dynamic lung compliance was 30 mL/cmH2O and PaO2/FiO2 ratio stayed above 150, with no need of prone positioning. On 5th day of IMV, cervical, thoracic and abdominal subcutaneous emphysema were noted on physical exam and pneumomediastinum was suspected on chest X-ray. Abdominal distension and tympanic percussion were also observed, with tangential X-ray of abdomen showing free gas in abdominal cavity . A thoraco-abdominal computed tomography (CT) scan was performed and confirmed subcutaneous emphysema, moderate pneumomediastinum and a large pneumoperitoneum, without pneumothorax, tracheoesophageal rupture, or signs of visceral perforation . In the absence of bowel perforation and other clinical consequences, the multidisciplinary team (intensivists and general surgeons) decided to manage conservatively the SP. However, 12 hours later, the patient became unstable. Lung mechanics were changed (tidal volumes and lung compliance decreased, peak inspiratory and mean airway pressures increased), hypoxemia worsened and intra-abdominal pressure (IAP) increased without signs of pneumothorax. An abdominal compartment syndrome (IAP 25 mmHg and respiratory disfunction) developed, and emergency percutaneous needle abdominal decompression with a 14-G venous catheter was performed . The catheter was connected to an underwater seal drainage system , with clinical improvement allowing catheter removal after three days, with complete resolution and no relapse of the pneumoperitoneum. He did not present any features suggestive of gastrointestinal tract perforation (nausea, vomiting, diarrhoea, abdominal pain, or hemodynamic instability). Thereafter, abdominal examination remained normal, enteral feeding was fully tolerated and bowel function remained normal.\nDue to prolonged mechanical ventilation, critical illness polyneuropathy and delirium, a percutaneous tracheostomy was performed on day 22 of IMV. The patient was discharged to the ward 48 days after ICU admission and left the hospital on day 129.", + "fulltext_subclaims": [ + "A 70-year-old man presented to the Emergency Department with 4 days of increasing shortness of breath and fatigue.", + "He had a positive SARS-CoV-2 screening test 15 days before.", + "His past medical history included arterial hypertension.", + "His past medical history included rheumatoid arthritis.", + "His past medical history included prostate cancer under radiotherapy and hormone therapy.", + "At ED, he denied fever, chills, chest and abdominal pain, nausea, or vomiting.", + "He was breathless, tachypneic, and severely hypoxemic with a peripheral oxygen saturation of 64% under room air.", + "Chest examination revealed bilateral crackles and wheezing.", + "Arterial blood gas analysis showed a respiratory alkalosis and hypoxemia.", + "The PaO2/FiO2 ratio was 170.", + "C-reactive protein was 43.73 mg/dL.", + "D-dimer was 35 200 ng/mL.", + "Acute kidney injury AKIN 2 was present.", + "The chest X-ray revealed bilateral reticulonodular infiltrates and linear opacities with a predominantly peripheral distribution.", + "The patient was diagnosed with COVID-19 pneumonia.", + "He was admitted to the general ward.", + "Dexamethasone was promptly started.", + "Therapeutic-dose anticoagulation was started.", + "Diuretic therapy was started.", + "In the first 48h he developed severe respiratory failure.", + "He was transferred to the ICU.", + "He required IMV after a failed trial of NIV.", + "Neuromuscular blocking agents were applied during the first 72h.", + "Recruitment manoeuvres were applied once by stepwise approach reaching a peak inspiratory pressure of 35 cmH2O.", + "Oxygenation and pulmonary compliance improved without haemodynamic instability.", + "Lung-protective ventilation was maintained with low tidal volume around 6 mL/Kg of predicted body weight.", + "Dynamic lung compliance was 30 mL/cmH2O.", + "The PaO2/FiO2 ratio stayed above 150.", + "On 5th day of IMV, cervical, thoracic and abdominal subcutaneous emphysema were noted on physical exam.", + "A thoraco-abdominal computed tomography (CT) scan was performed.", + "The CT scan confirmed subcutaneous emphysema.", + "The CT scan confirmed moderate pneumomediastinum.", + "The CT scan confirmed a large pneumoperitoneum.", + "The multidisciplinary team decided to manage conservatively the SP.", + "12 hours later, the patient became unstable.", + "An emergency percutaneous needle abdominal decompression with a 14-G venous catheter was performed.", + "The catheter was connected to an underwater seal drainage system.", + "The catheter was removed after three days.", + "The pneumoperitoneum resolved completely.", + "The patient did not present any features suggestive of gastrointestinal tract perforation.", + "A percutaneous tracheostomy was performed on day 22 of IMV.", + "The patient was discharged to the ward 48 days after ICU admission.", + "The patient left the hospital on day 129." + ], + "summary": "We present the case of a 70-year-old man with COVID-19 pneumonia admitted to the Intensive Care Unit (ICU). Since admission he was on Non-Invasive Ventilation (NIV), without improvement, needing Invasive Mechanical Ventilation (IMV) due to severe respiratory failure. Five days after IMV despite protective lung ventilation, massive spontaneous subcutaneous emphysema, pneumomediastinum and pneumoperitoneum were diagnosed. Besides initial conservative management 12 hours later, the patient developed abdominal compartment syndrome requiring percutaneous needle decompression.", + "summary_subclaims": [ + "The patient is a 70-year-old man.", + "The patient had COVID-19 pneumonia.", + "The patient was admitted to the Intensive Care Unit.", + "Since admission, the patient was on Non-Invasive Ventilation.", + "The patient needed Invasive Mechanical Ventilation due to severe respiratory failure.", + "Five days after Invasive Mechanical Ventilation, massive spontaneous subcutaneous emphysema was diagnosed.", + "Five days after Invasive Mechanical Ventilation, pneumomediastinum was diagnosed.", + "Five days after Invasive Mechanical Ventilation, pneumoperitoneum was diagnosed.", + "The patient received initial conservative management.", + "Twelve hours after conservative management, the patient developed abdominal compartment syndrome.", + "The patient required percutaneous needle decompression." + ] + }, + { + "id": "multiclinsum_test_3066_en.txt", + "fulltext": "A 56-year-old male with a history of right lower limb arteriovenous malformation, diagnosed when he was 2 years’ old, was living in Tomioka Town, located 5 to 14 kilometers south from the FDNPP, before the FDNPP accident. He was recognized as having a grade 3 extremity disability (a unilateral lower limb that does not function completely) by the Act for the Welfare of Persons with Physical Disabilities in Japan. Although his right lower limb was difficult to use, he could walk using crutches. Some support was necessary from his family members; however, he had been able to live without limitations in daily activities before the disaster.\n\nOn March 11 in 2011, the patient experienced the Great East Japan Earthquake while at his home with his family. The tsunami did not reach their house. The next day, the Japanese central government declared Tomioka town as part of the mandatory evacuation zone. The patient and his family immediately evacuated to an evacuation center in Tamura city, 40 km west from their home. Although the evacuation center was open to all evacuees, no space was particularly prepared for people with physical disabilities, leading our patient to spend almost all of his time in his car because he felt that his existence in the public space may become a nuisance to others. Several days later, he moved to a room in a hotel in Koriyama city, 60 km west from Tomioka town. Dramatic environmental changes from repeated evacuations imposed a significant physical burden to our patient. He also experienced psychological stress, feeling that he was imposing a strain on family because he thought that his existence prevented his family from being able to freely evacuate.\n\nThree months after initial evacuation, he was referred to a hospital near the hotel in Koriyama city, with symptoms of fever and palpitation. He was admitted to the hospital with a new diagnosis of atrial fibrillation and congestive cardiac failure. During this admission there was deterioration of his right lower limb arteriovenous malformation, located between his abdominal aorta and right femoral artery, which caused a right foot ulcer. He was treated with anticoagulation therapy and diuretic therapy, and was discharged from the hospital approximately one month after the admission, although his foot ulcer required frequent care because it was refractory after hospital discharge.\n\nThe hospital admission after repeated evacuations notably weakened our patient's physical activity. After hospital discharge (approximately 4 months after his initial evacuation from Tomioka town), he moved into a temporary house constructed for evacuees in Koriyama city because the mandatory evacuation order continued. Although he could not ambulate, dress, or bathe himself without support, he did not need support for eating and using the toilet. The temporary house presented a particularly difficult environment for someone with a physical disability; unpaved roads around the house severely limited his opportunities to go outside and the bath was too narrow to use while requiring support from family.\n\nHis physical condition gradually worsened. Continuation of frequent care, such as washing and applying ointments, did not improve his foot ulcer. Following a detailed medical examination in February 2012, which revealed that his arteriovenous malformation was no longer eligible for aggressive intervention, he decided to only be treated with supportive therapy. From August 2012, he became confined to bed and required assistance for all activities of daily living. In July 2013, he was no longer able to go out to temporarily visit his original home in the evacuation zone, which had been only thing he looked forward to. He prioritized time with his family, did not like being admitted to hospital, and did not seek medical care outside of periodic visits to the clinic. Although he was hardly eating, and was aware of pain in his right limb and shortness of breath from December 2013, he did not visit the hospital. In the middle of a night in February 2014, he was transported to the hospital after massive bleeding from his right foot ulcer. After admission to the hospital, infection to the ulcer was found in addition to refractory bleeding. Despite blood infusion therapy and antibiotic therapy, he died of septic shock 18 days after admission.", + "fulltext_subclaims": [ + "The patient was a 56-year-old male.", + "He had a history of right lower limb arteriovenous malformation.", + "The arteriovenous malformation was diagnosed when he was 2 years old.", + "He was living in Tomioka Town before the FDNPP accident.", + "Tomioka Town was located 5 to 14 kilometers south from the FDNPP.", + "He was recognized as having a grade 3 extremity disability.", + "The grade 3 extremity disability was recognized by the Act for the Welfare of Persons with Physical Disabilities in Japan.", + "His right lower limb did not function completely.", + "He could walk using crutches.", + "Some support was necessary from his family members.", + "He had been able to live without limitations in daily activities before the disaster.", + "On March 11 in 2011, the patient experienced the Great East Japan Earthquake.", + "The patient was at his home with his family during the earthquake.", + "The tsunami did not reach their house.", + "The Japanese central government declared Tomioka town as part of the mandatory evacuation zone the next day.", + "The patient and his family immediately evacuated to an evacuation center in Tamura city.", + "Tamura city was 40 km west from their home.", + "The evacuation center was open to all evacuees.", + "No space was particularly prepared for people with physical disabilities.", + "The patient spent almost all of his time in his car.", + "He felt that his existence in the public space may become a nuisance to others.", + "Several days later, he moved to a room in a hotel in Koriyama city.", + "Koriyama city was 60 km west from Tomioka town.", + "Dramatic environmental changes from repeated evacuations imposed a significant physical burden to our patient.", + "He also experienced psychological stress.", + "He felt that he was imposing a strain on family.", + "He thought that his existence prevented his family from being able to freely evacuate.", + "Three months after initial evacuation, he was referred to a hospital near the hotel in Koriyama city.", + "He had symptoms of fever and palpitation.", + "He was admitted to the hospital with a new diagnosis of atrial fibrillation.", + "He was admitted to the hospital with a new diagnosis of congestive cardiac failure.", + "During this admission, there was deterioration of his right lower limb arteriovenous malformation.", + "The arteriovenous malformation was located between his abdominal aorta and right femoral artery.", + "The arteriovenous malformation caused a right foot ulcer.", + "He was treated with anticoagulation therapy.", + "He was treated with diuretic therapy.", + "He was discharged from the hospital approximately one month after the admission.", + "His foot ulcer required frequent care because it was refractory after hospital discharge.", + "The hospital admission after repeated evacuations notably weakened our patient's physical activity.", + "After hospital discharge, he moved into a temporary house constructed for evacuees in Koriyama city.", + "The mandatory evacuation order continued.", + "He could not ambulate, dress, or bathe himself without support.", + "He did not need support for eating and using the toilet.", + "The temporary house presented a particularly difficult environment for someone with a physical disability.", + "Unpaved roads around the house severely limited his opportunities to go outside.", + "The bath was too narrow to use while requiring support from family.", + "His physical condition gradually worsened.", + "Continuation of frequent care, such as washing and applying ointments, did not improve his foot ulcer.", + "Following a detailed medical examination in February 2012, his arteriovenous malformation was no longer eligible for aggressive intervention.", + "He decided to only be treated with supportive therapy.", + "From August 2012, he became confined to bed.", + "He required assistance for all activities of daily living.", + "In July 2013, he was no longer able to go out to temporarily visit his original home in the evacuation zone.", + "He prioritized time with his family.", + "He did not like being admitted to hospital.", + "He did not seek medical care outside of periodic visits to the clinic.", + "Although he was hardly eating, he did not visit the hospital.", + "He was aware of pain in his right limb and shortness of breath from December 2013.", + "He did not visit the hospital.", + "In the middle of a night in February 2014, he was transported to the hospital after massive bleeding from his right foot ulcer.", + "After admission to the hospital, infection to the ulcer was found.", + "Refractory bleeding was also found.", + "Despite blood infusion therapy and antibiotic therapy, he died of septic shock.", + "He died 18 days after admission." + ], + "summary": "Patient concerns:\nA 56-year-old physically challenged male with arteriovenous malformation on his right lower limb, diagnosed when he was 2 years’ old, lived near the FDNPP. He and his family were forced to evacuate immediately after the accident.\n\nDiagnosis:\nThree months after evacuation following the FDNPP accident, he developed a refractory foot ulcer associated with atrial fibrillation and congestive cardiac failure because of deterioration of arteriovenous malformation, presumably led by repeated evacuations.\n\nIntervention:\nAlthough anticoagulation therapy and diuretic therapy improved his cardiac failure in the initial admission, he decided to only be treated with supportive care after revelation that his arteriovenous malformation was no longer eligible for aggressive intervention.\n\nOutcome:\nThree years after the long-term evacuation in temporary houses, the patient died of bleeding and infection of the ulcer.", + "summary_subclaims": [ + "The patient is a 56-year-old physically challenged male.", + "He has an arteriovenous malformation on his right lower limb.", + "The arteriovenous malformation was diagnosed when he was 2 years old.", + "He lived near the FDNPP.", + "He and his family were forced to evacuate immediately after the accident.", + "Three months after evacuation, he developed a refractory foot ulcer.", + "The foot ulcer was associated with atrial fibrillation and congestive cardiac failure.", + "The deterioration of arteriovenous malformation was presumably led by repeated evacuations.", + "Anticoagulation therapy and diuretic therapy improved his cardiac failure in the initial admission.", + "He decided to only be treated with supportive care.", + "He was told that his arteriovenous malformation was no longer eligible for aggressive intervention.", + "Three years after long-term evacuation in temporary houses, the patient died.", + "The patient died of bleeding and infection of the ulcer." + ] + }, + { + "id": "multiclinsum_test_1986_en.txt", + "fulltext": "A 46-year-old female patient was admitted to our department on December 12, 2019 due to the presence of abdominal and back pain for 2 d and aggravation of these symptoms for 1 d.\nThe patient had no obvious inducement for upper abdominal pain or back pain 2 d before admission. Her discomfort was mainly located in the middle and upper left abdomen, and she exhibited persistent, paroxysmal aggravation; no nausea and vomiting; and no fever and chills. At the outpatient department of our hospital one day prior, after first ruling out angina pectoris, the patient was sent to the Department of Cardiology, where cardiac enzyme analyses, electrocardiograms, and other tests were performed to rule out ischemic heart diseases; next, she went to the emergency department of our hospital to undergo laboratory analyses. Amylase levels were normal and routine blood tests showed normal white blood cells and a haemoglobin (Hb) level of 125 g/L. After symptomatic treatment, the patient’s abdominal pain worsened, and she was admitted to the Department of Gastroenterology.\nThe patient reported no history of chronic abdominal pain, upper abdominal murmur, or weight loss during the disease course. She reported a history of “arrhythmia” for 3 years, and no history of hypertension, diabetes, coronary heart disease, etc.; additionally, she had no history of pancreatitis or abdominal trauma and no family history of genetic diseases.\nN/A.\nThe patient’s body temperature was 36.8 °C, blood pressure was 120/80 mmHg (1 mmHg = 0.133 kPa), and heart rate was 100 beats/min. She had a face of acute ill, painful expression, clear consciousness, mild pallid eyelid conjunctiva, flat abdomen, tenderness and rebound pain throughout the abdomen, no obvious mass, and no muscle tension. No murmurs were heard in the upper abdomen on inhalation or exhalation.\nThe blood test showed that Hb was 88 g/L, liver and kidney function was normal, C-reactive protein was 12 mg/L, and blood and urinary amylase levels were normal.\nComputed tomography (CT) of the abdomen revealed haematomas around the head of the pancreas and retroperitoneum. To further determine the cause of the haematoma, CT and CT angiography (CTA) examinations of the whole abdomen were performed, suggesting a superior mesenteric artery (SMA) mural thrombus , with stenosis of the lumen, local pancreaticoduodenal artery dilation, 1.2 cm wide diameter , uneven thickness , and a haematoma around the head of the pancreas and retroperitoneum. Moreover, an abnormal collateral vessel was formed between the gastroduodenal artery and the SMA. The preliminary diagnosis was “retroperitoneal haemorrhage, PDAA, and SMA mural thrombus”. The cause of bleeding was considered to be PDAA rupture. The blood examination showed an Hb level of 69 g/L, and the red blood cell suspension was used to correct anaemia. Because the patient was critically ill and our hospital has not yet performed coil vascular embolism and interventional therapy, surgical exploration was performed in combination with the above conditions.\nAfter layer-by-layer laparotomy, the omentum and gastrocolic ligament were dissociated along the greater curvature of the stomach to expose the retroperitoneal hematoma and remove the hematoma adjacent to the duodenum and above the pancreas. The hepatoduodenal ligament was dissected and the gastroduodenal artery isolated. There was active bleeding approximately 1 cm below the branch of the gastroduodenal artery. PDAA rupture was ruled out due to the location of the bleeding. We read the enhanced CT and the CTA films in detail, and found that the initial segments of the celiac artery and SMA were narrow and that the celiac artery origin was V-shaped . In addition, abnormal collateral blood vessels were formed between the arteria gastroduodenalis and the SMA.", + "fulltext_subclaims": [ + "The patient was admitted on December 12, 2019.", + "The patient had abdominal and back pain for 2 d before admission.", + "The patient had no obvious inducement for upper abdominal pain or back pain 2 d before admission.", + "The discomfort was mainly located in the middle and upper left abdomen.", + "The patient exhibited persistent, paroxysmal aggravation.", + "The patient had no nausea and vomiting.", + "The patient had no fever and chills.", + "At the outpatient department, cardiac enzyme analyses were performed.", + "Electrocardiograms were performed to rule out ischemic heart diseases.", + "Amylase levels were normal.", + "Routine blood tests showed normal white blood cells.", + "The patient’s abdominal pain worsened after symptomatic treatment.", + "The patient was admitted to the Department of Gastroenterology.", + "The patient reported a history of “arrhythmia” for 3 years.", + "The patient had no history of hypertension.", + "The patient had no history of diabetes.", + "The patient had no history of coronary heart disease.", + "The patient had no history of pancreatitis.", + "The patient had no history of abdominal trauma.", + "The patient had no family history of genetic diseases.", + "The patient’s body temperature was 36.8 °C.", + "The patient’s blood pressure was 120/80 mmHg.", + "The patient’s heart rate was 100 beats/min.", + "The patient had a face of acute ill, painful expression.", + "The patient had clear consciousness.", + "The patient had mild pallid eyelid conjunctiva.", + "The patient had tenderness and rebound pain throughout the abdomen.", + "The patient had no obvious mass.", + "The patient had no muscle tension.", + "No murmurs were heard in the upper abdomen on inhalation or exhalation.", + "The blood test showed Hb was 88 g/L.", + "Computed tomography (CT) of the abdomen revealed haematomas around the head of the pancreas and retroperitoneum.", + "CTA examinations of the whole abdomen were performed.", + "The CT and CTA suggested a superior mesenteric artery (SMA) mural thrombus.", + "The SMA mural thrombus had stenosis of the lumen.", + "The pancreaticoduodenal artery had a 1.2 cm wide diameter.", + "The pancreaticoduodenal artery had uneven thickness.", + "An abnormal collateral vessel was formed between the gastroduodenal artery and the SMA.", + "The preliminary diagnosis was “retroperitoneal haemorrhage, PDAA, and SMA mural thrombus.”", + "The cause of bleeding was considered to be PDAA rupture.", + "The blood examination showed an Hb level of 69 g/L.", + "Red blood cell suspension was used to correct anaemia.", + "The patient was critically ill.", + "Our hospital has not yet performed coil vascular embolism and interventional therapy.", + "Surgical exploration was performed.", + "After laparotomy, the omentum and gastrocolic ligament were dissociated.", + "The retroperitoneal hematoma was removed.", + "The hepatoduodenal ligament was dissected.", + "The gastroduodenal artery was isolated.", + "There was active bleeding approximately 1 cm below the branch of the gastroduodenal artery.", + "PDAA rupture was ruled out due to the location of the bleeding.", + "The initial segments of the celiac artery and SMA were narrow.", + "The celiac artery origin was V-shaped.", + "Abnormal collateral blood vessels were formed between the arteria gastroduodenalis and the SMA." + ], + "summary": "This article describes a 46-year-old female patient who was admitted to our hospital with abdominal pain as her chief complaint. She had experienced no obvious symptoms but had retroperitoneal bleeding during the course of the disease. Contrast-enhanced computed tomography (CT) and noninvasive CT angiography (CTA) led to an initial misdiagnosis of pancreaticoduodenal artery aneurysm (PDAA) causing retroperitoneal hemorrhage. After intraoperative exploration and detailed analysis of enhanced CT and CTA images, a final diagnosis of MALS was made. The cause of the haemorrhage was bleeding from a branch of the gastroduodenal artery, not rupture of a PDAA. The prognosis of MALS combined with PDAA treated by laparoscopy and interventional therapy is still acceptable. The patient was temporarily treated by gastroduodenal suture haemostasis and was referred for further treatment.", + "summary_subclaims": [ + "The patient was a 46-year-old female.", + "The patient was admitted to the hospital with abdominal pain as her chief complaint.", + "She had experienced no obvious symptoms.", + "She had retroperitoneal bleeding during the course of the disease.", + "Contrast-enhanced computed tomography (CT) and noninvasive CT angiography (CTA) led to an initial misdiagnosis of pancreaticoduodenal artery aneurysm (PDAA) causing retroperitoneal hemorrhage.", + "After intraoperative exploration and detailed analysis of enhanced CT and CTA images, a final diagnosis of MALS was made.", + "The cause of the haemorrhage was bleeding from a branch of the gastroduodenal artery.", + "The cause of the haemorrhage was not rupture of a PDAA.", + "The prognosis of MALS combined with PDAA treated by laparoscopy and interventional therapy is still acceptable.", + "The patient was temporarily treated by gastroduodenal suture haemostasis.", + "The patient was referred for further treatment." + ] + }, + { + "id": "multiclinsum_test_377_en.txt", + "fulltext": "A 58 year-old gentleman presented to the hospital with worsening bloating and a gradual increase in his abdominal girth. He had also noted a loss of weight of more than 10 kg over the last 2 years. The patient otherwise denied any abdominal pain or change in his bowel habit. He was known to have a history of well-controlled diabetes mellitus, hypertension, hyperlipidaemia and atrial fibrillation. There was no previous history of pancreatitis or abdominal surgery. The patient had recently undergone a gastroscopy and colonoscopy the previous year for iron deficiency anaemia. This had shown gastritis as well as the presence of pandiverticular disease and a sub-centimeter colonic polyp. Histology showed the polyp to be a tubular adenoma with low-grade dysplasia (, , , , , ).\nClinical examination showed an adequately nourished gentleman but with a large abdominal mass occupying most of his abdomen. It was possible to feel over the superior edge but the inferior edge extended into the pelvis. The mass was non-tender on palpation. Digital rectal examination was unremarkable.\nIn view of the above findings, the patient underwent a computed tomography (CT) of the abdomen and pelvis. This showed a large 25 × 17 × 22 cm cystic lesion extending from the mid-abdomen to the pelvis. The lesion was thin walled and contained homogenous low density fluid (14 Hounsfield unit). There was no septations, irregularity or abnormal thickening of the cyst wall. The cyst was noted to have a mass effect but not invading the surrounding bowel loops and the urinary bladder. It was found to be separate from the liver and the kidneys. The pancreas was normal in appearance. The CT scan was otherwise unable to identify the origin of the giant cyst.\nAs this was a thin walled cyst with no irregular or solid component, a fine needle aspiration (FNA) was not suitable as there was no specific area to target. Aspiration of the fluid was also unlikely to yield any meaningful finding for diagnosis. Further imaging such as a MRI would also not help in identifying the origin or the diagnosis of the cyst. The possibility of a mesenteric or omental cyst was therefore discussed and surgical excision was offered to the patient. Tumour markers were not performed as it would not have affected the management.\nAn elective exploratory laparotomy was performed via a midline incision. A giant cyst was immediately identified but was found to have multiple adhesions to the peritoneum, omentum, mesentery, urinary bladder as well as the small and large intestines. However, the cyst was not found to be originating from any of the above organs or the vas deferens. The cyst was entirely within the abdominal cavity and did not originate from within the mesentery. A controlled decompression of the cyst was made through a purse-string encircled incision in the anterior wall. This was performed to aid with retraction and visualization of the posterior surface. Thick purulent fluid was aspirated until dry. The cyst was subsequently excised in whole.\nThe patient underwent an uneventful recovery with a brief period of expected post-operative ileus. He was discharged on post-operative day 6. Follow-up visits showed complete resolution of his initial symptoms and a vast improvement in his appetite.\nCulture of the fluid was positive for Streptococcus agalactiae. Fungal culture and tuberculosis polymerase chain reaction (TB PCR) tests were negative. Cytology of the fluid showed mainly neutrophils.\nHistological examination of the cyst showed thick fibrous walls covered with coarse fibrillary strands admixed with fibrin. There were also large numbers of mature IgG plasma cells with aggregates of neutrophils and scattered lymphocytes. No viable epithelial lining was identified. The walls stained positive for AE1/3 suggesting myofibroblasts. They were negative for CD117 and DOG-1 and therefore not suggestive of a gastrointestinal stromal tumour.\nThis was therefore treated as a benign cyst of an undetermined origin.\nThe patient was last seen in clinic two months after his surgery with a significant improvement in his appetite and oral intake. He was thereafter discharged from follow-up as the likelihood of recurrence was low considering that the cyst had been excised entirely with no remnant wall left behind.", + "fulltext_subclaims": [ + "The patient is a 58 year-old gentleman.", + "He presented with worsening bloating.", + "He had a gradual increase in his abdominal girth.", + "He had noted a loss of weight of more than 10 kg over the last 2 years.", + "He denied any abdominal pain.", + "He denied any change in his bowel habit.", + "He had a history of well-controlled diabetes mellitus.", + "He had a history of hypertension.", + "He had a history of hyperlipidaemia.", + "He had a history of atrial fibrillation.", + "He had no previous history of pancreatitis.", + "He had no previous history of abdominal surgery.", + "He had recently undergone a gastroscopy and colonoscopy the previous year.", + "The gastroscopy and colonoscopy were performed for iron deficiency anaemia.", + "The gastroscopy and colonoscopy showed gastritis.", + "The gastroscopy and colonoscopy showed the presence of pandiverticular disease.", + "The gastroscopy and colonoscopy showed a sub-centimeter colonic polyp.", + "Histology showed the polyp to be a tubular adenoma with low-grade dysplasia.", + "Clinical examination showed a large abdominal mass.", + "The mass occupied most of his abdomen.", + "The mass was non-tender on palpation.", + "Digital rectal examination was unremarkable.", + "The patient underwent a computed tomography (CT) of the abdomen and pelvis.", + "The CT showed a large 25 × 17 × 22 cm cystic lesion.", + "The lesion extended from the mid-abdomen to the pelvis.", + "The lesion was thin walled.", + "The lesion contained homogenous low density fluid (14 Hounsfield unit).", + "There was no septations.", + "There was no irregularity.", + "There was no abnormal thickening of the cyst wall.", + "The cyst had a mass effect.", + "The cyst was not invading the surrounding bowel loops.", + "The cyst was not invading the urinary bladder.", + "The cyst was separate from the liver.", + "The cyst was separate from the kidneys.", + "The pancreas was normal in appearance.", + "The CT scan was unable to identify the origin of the giant cyst.", + "A fine needle aspiration (FNA) was not suitable.", + "Aspiration of the fluid was unlikely to yield any meaningful finding for diagnosis.", + "Further imaging such as a MRI would not help in identifying the origin or the diagnosis of the cyst.", + "The possibility of a mesenteric or omental cyst was discussed.", + "Surgical excision was offered to the patient.", + "Tumour markers were not performed.", + "An elective exploratory laparotomy was performed via a midline incision.", + "A giant cyst was immediately identified.", + "The cyst had multiple adhesions to the peritoneum.", + "The cyst had multiple adhesions to the omentum.", + "The cyst had multiple adhesions to the mesentery.", + "The cyst had multiple adhesions to the urinary bladder.", + "The cyst had multiple adhesions to the small and large intestines.", + "The cyst was not found to be originating from any of the above organs.", + "The cyst was not found to be originating from the vas deferens.", + "The cyst was entirely within the abdominal cavity.", + "The cyst did not originate from within the mesentery.", + "A controlled decompression of the cyst was made through a purse-string encircled incision in the anterior wall.", + "Thick purulent fluid was aspirated until dry.", + "The cyst was excised in whole.", + "The patient had an uneventful recovery.", + "He was discharged on post-operative day 6.", + "Follow-up visits showed complete resolution of his initial symptoms.", + "There was a vast improvement in his appetite.", + "Culture of the fluid was positive for Streptococcus agalactiae.", + "Fungal culture was negative.", + "TB PCR was negative.", + "Cytology of the fluid showed mainly neutrophils.", + "Histological examination showed thick fibrous walls covered with coarse fibrillary strands.", + "The walls were admixed with fibrin.", + "There were large numbers of mature IgG plasma cells.", + "There were aggregates of neutrophils.", + "There were scattered lymphocytes.", + "No viable epithelial lining was identified.", + "The walls stained positive for AE1/3.", + "The walls were negative for CD117.", + "The walls were negative for DOG-1.", + "This was treated as a benign cyst of an undetermined origin.", + "The patient was last seen in clinic two months after his surgery.", + "There was a significant improvement in his appetite.", + "There was a significant improvement in his oral intake.", + "He was discharged from follow-up.", + "The likelihood of recurrence was low." + ], + "summary": "Here, we present a case of a 58 year-old gentleman with worsening bloating and abdominal distension. A contrasted CT scan of the abdomen revealed a giant intra-abdominal cyst with no definite organ of origin. He underwent a laparotomy and excision of the giant cyst which was not found to be attached to any organ or mesentery. This resulted in resolution of his symptoms and a drastic improvement in his appetite.", + "summary_subclaims": [ + "The patient is a 58 year-old gentleman.", + "He had worsening bloating and abdominal distension.", + "A contrasted CT scan of the abdomen revealed a giant intra-abdominal cyst.", + "The CT scan showed no definite organ of origin for the cyst.", + "He underwent a laparotomy and excision of the giant cyst.", + "The cyst was not found to be attached to any organ or mesentery.", + "The excision resulted in resolution of his symptoms.", + "The excision resulted in a drastic improvement in his appetite." + ] + }, + { + "id": "multiclinsum_test_3287_en.txt", + "fulltext": "The patient was born at 39 weeks of gestation and delivered by Cesarean section due to polyhydramnios. She was 3295 g at birth. Although short stature and abnormal facial features such as depressed nose, deeply grooved philtrum, and macroglossia were recognized at birth, the signs were not associated with any particular diagnosis. At 1 year of age, she was diagnosed with pulmonary valve stenosis. At 5 years of age, a balloon valvuloplasty for severe PS was performed; however, it was not sufficient to reduce the pressure gradient of PS (from 80 mmHg to 50 mmHg). At 6 years of age, surgical valvuloplasty to enlarge the annulus and reconstruct the right ventricular outflow tract was performed, which resulted in the disappearance of the PS pressure gradient. She was followed-up at our hospital yearly. Although echocardiogram showed mild PR, her clinical condition was good without specific medical treatment. When she was a high school student, she discontinued regular medical follow-up, and started studying abroad at 18 years of age. She occasionally experienced transient leg edema during this time. At 21 years of age, she developed dyspnea, edema, and abdominal bloating. She returned to Japan; thereafter, she required an emergency hospitalization. She was diagnosed with acute decompensated heart failure, which was mainly right-sided heart failure due to severe PR and TR. It was thought that PR had been subclinically exacerbated after the surgical valvuloplasty, resulting in right-ventricular volume overload. She was also diagnosed with protein-losing enteropathy associated with abnormalities in lymphatic drainage. Echocardiography showed no evidence of HCM, MS, or PS recurrence. Cardiac catheterization revealed a normal cardiac index of 3.9 L/min/m2, and a normal estimated mitral valve area of 4.13 cm2/m2. On the basis of the history of PS and characteristic physical features including short stature, webbed neck, and hypertelorism, she was clinically diagnosed with NS for the first time. A chromosomal study showed 46XX with no abnormality of chromosome 12. The patient refused genetic testing. She was successfully treated with a loop diuretic, beta-blocker, angiotensin-converting enzyme inhibitor, and aldosterone inhibitor. After discharge, she resumed regular follow-up at the local hospital. Although the symptoms of heart failure, such as dyspnea and edema, persisted with a New York Heart Association class of II these symptoms could be controlled with oral medical treatment. There were no records regarding the follow-up echocardiographic findings at the local hospital. At 25 years of age, she was admitted to the local hospital again for massive ascites and marked edema and was referred to our hospital. Her height was 107 cm and her weight was 33 kg. She had a body temperature of 36.8 °C, blood pressure of 90/50 mmHg, regular pulse rate of 125 beats/min, respiratory rate of 18 breaths/min, and oxygen saturation of 95% without oxygen administration. On physical examination, she exhibited jugular venous distention at her neck, and systolic and diastolic regurgitant murmur at the left sternal border. Her breath sounds were decreased, and she had abdominal distention with no tenderness and significant leg edema. Laboratory data upon hospitalization are shown in Table 1. Chest radiography showed heart enlargement with cardiothoracic ratio of 63%, pulmonary edema, and bilateral pleural effusion. Electrocardiogram showed sinus tachycardia with right axis deviation. Echocardiogram showed enlargement of the right-side heart with displacement of the ventricular septal wall, as well as severe PR, TR, and severe MS with a mean pressure gradient of 10 mmHg and mild thickening of the mitral valve leaflets. Since diastolic function based on the early diastolic mitral septal annular velocity was normal, it was unlikely that the patient had restrictive cardiomyopathy or constrictive pericarditis. Cardiac catheterization revealed a mean pulmonary artery pressure of 49 mmHg, a mean pulmonary artery wedge pressure of 33 mmHg, a left ventricular end-diastolic pressure of 24 mmHg, a low cardiac index of 1.9 L/min/m2, and confirmed severe MS with an estimated mitral valve area of 0.81 cm2/m2. Coronary arteries were intact. There was no evidence of rheumatic change or infectious endocarditis; the etiology of the late-onset MS was uncertain. Computed tomography of the chest and abdomen showed massive ascites as well as plural effusion and atelectasis in the right lung. On the basis of these findings, she was diagnosed with heart failure of both sides, which was mainly caused by severe PR and TR after surgical valvuloplasty for PS as well as the late-onset severe MS with uncertain etiology. Moreover, her abdominal ultrasonogram findings, including irregular external contour, enlarged left liver lobe, and splenomegaly, indicated that she had developed cirrhosis. This was thought to be associated with long-standing right-side heart failure, because of the negative viral or other hepatitis screening. Results of the analysis of ascites and plural effusion were consistent with a pure transudate. Thus, excessive fluid of the chest and abdomen was considered to have been caused by the chronic right-side heart failure in addition to the severe hypoalbuminemia associated with advanced cirrhosis and protein-losing enteropathy. In addition to the abdominal and chest drainage, fluid management using furosemide, tolvaptan, and carperitide was successfully performed. We discussed a treatment strategy with surgeons, including mitral valve replacement, tricuspid valvuloplasty, and right ventricular outflow tract reconstruction; however, considering the patient’s low left ventricular function, cirrhosis, very low albumin level, and atelectasis caused by the long-standing pleural effusion, surgical options were considered to be extremely high risk. In addition, transcatheter cardiac intervention could not be performed in Japan at that time. Therefore, we continued the optimal medication treatment as well as the occasional abdominal cavity drainage for recurrent ascites. Unfortunately, after repeated hospitalizations for ascites and edema, she died of decompensated heart failure 2 years later.", + "fulltext_subclaims": [ + "The patient was born at 39 weeks of gestation.", + "The patient was delivered by Cesarean section due to polyhydramnios.", + "The patient weighed 3295 g at birth.", + "Short stature and abnormal facial features were recognized at birth.", + "The signs were not associated with any particular diagnosis.", + "At 1 year of age, she was diagnosed with pulmonary valve stenosis.", + "At 5 years of age, a balloon valvuloplasty for severe PS was performed.", + "The balloon valvuloplasty was not sufficient to reduce the pressure gradient of PS (from 80 mmHg to 50 mmHg).", + "At 6 years of age, surgical valvuloplasty to enlarge the annulus and reconstruct the right ventricular outflow tract was performed.", + "The surgical valvuloplasty resulted in the disappearance of the PS pressure gradient.", + "She was followed-up at our hospital yearly.", + "Echocardiogram showed mild PR.", + "Her clinical condition was good without specific medical treatment.", + "She discontinued regular medical follow-up when she was a high school student.", + "She started studying abroad at 18 years of age.", + "She occasionally experienced transient leg edema during this time.", + "At 21 years of age, she developed dyspnea, edema, and abdominal bloating.", + "She returned to Japan.", + "She required an emergency hospitalization.", + "She was diagnosed with acute decompensated heart failure.", + "The heart failure was mainly right-sided heart failure due to severe PR and TR.", + "It was thought that PR had been subclinically exacerbated after the surgical valvuloplasty.", + "Echocardiography showed no evidence of HCM, MS, or PS recurrence.", + "Cardiac catheterization revealed a normal cardiac index of 3.9 L/min/m2.", + "Cardiac catheterization revealed a normal estimated mitral valve area of 4.13 cm2/m2.", + "On the basis of the history of PS and characteristic physical features, she was clinically diagnosed with NS for the first time.", + "A chromosomal study showed 46XX with no abnormality of chromosome 12.", + "The patient refused genetic testing.", + "She was successfully treated with a loop diuretic, beta-blocker, angiotensin-converting enzyme inhibitor, and aldosterone inhibitor.", + "After discharge, she resumed regular follow-up at the local hospital.", + "The symptoms of heart failure, such as dyspnea and edema, persisted with a New York Heart Association class of II.", + "These symptoms could be controlled with oral medical treatment.", + "There were no records regarding the follow-up echocardiographic findings at the local hospital.", + "At 25 years of age, she was admitted to the local hospital again for massive ascites and marked edema.", + "She was referred to our hospital.", + "Her height was 107 cm.", + "Her weight was 33 kg.", + "Her blood pressure was 90/50 mmHg.", + "Her pulse rate was 125 beats/min.", + "Her oxygen saturation was 95% without oxygen administration.", + "On physical examination, she exhibited jugular venous distention at her neck.", + "She had systolic and diastolic regurgitant murmur at the left sternal border.", + "Chest radiography showed heart enlargement with cardiothoracic ratio of 63%.", + "Chest radiography showed pulmonary edema.", + "Chest radiography showed bilateral pleural effusion.", + "Echocardiogram showed enlargement of the right-side heart with displacement of the ventricular septal wall.", + "Echocardiogram showed severe PR.", + "Echocardiogram showed severe TR.", + "Echocardiogram showed severe MS with a mean pressure gradient of 10 mmHg.", + "Echocardiogram showed mild thickening of the mitral valve leaflets.", + "Cardiac catheterization revealed a mean pulmonary artery pressure of 49 mmHg.", + "Cardiac catheterization revealed a mean pulmonary artery wedge pressure of 33 mmHg.", + "Cardiac catheterization revealed a left ventricular end-diastolic pressure of 24 mmHg.", + "Cardiac catheterization revealed a low cardiac index of 1.9 L/min/m2.", + "Cardiac catheterization confirmed severe MS with an estimated mitral valve area of 0.81 cm2/m2.", + "There was no evidence of rheumatic change or infectious endocarditis.", + "The etiology of the late-onset MS was uncertain.", + "Computed tomography showed massive ascites.", + "Computed tomography showed plural effusion.", + "Computed tomography showed atelectasis in the right lung.", + "She was diagnosed with heart failure of both sides.", + "The heart failure was mainly caused by severe PR and TR after surgical valvuloplasty for PS.", + "The heart failure was also caused by late-onset severe MS with uncertain etiology.", + "Abdominal ultrasonogram findings indicated that she had developed cirrhosis.", + "The cirrhosis was thought to be associated with long-standing right-side heart failure.", + "Results of the analysis of ascites and plural effusion were consistent with a pure transudate.", + "Excessive fluid of the chest and abdomen was considered to have been caused by chronic right-side heart failure.", + "Excessive fluid was also considered to have been caused by severe hypoalbuminemia associated with advanced cirrhosis and protein-losing enteropathy.", + "In addition to abdominal and chest drainage, fluid management using furosemide, tolvaptan, and carperitide was successfully performed.", + "We discussed a treatment strategy with surgeons, including mitral valve replacement, tricuspid valvuloplasty, and right ventricular outflow tract reconstruction.", + "Surgical options were considered to be extremely high risk.", + "Transcatheter cardiac intervention could not be performed in Japan at that time.", + "We continued optimal medication treatment.", + "We performed occasional abdominal cavity drainage for recurrent ascites.", + "She died of decompensated heart failure 2 years later." + ], + "summary": "We report a 25-year-old Japanese woman diagnosed with NS in adulthood. She exhibited short stature and minor facial dysmorphism and was diagnosed with PS at 1 year of age. After surgical valvuloplasty for PS at 6 years of age, her general condition became stable without specific medical treatment. She discontinued regular medical follow-up for PS. At 21 years of age, she developed acute decompensated heart failure, which was mainly right-sided heart failure due to severe pulmonary regurgitation (PR) and tricuspid regurgitation (TR). There was no evidence of HCM or PS recurrence. On the basis of the history of PS and characteristic physical features including short stature, webbed neck, and hypertelorism, she was clinically diagnosed with NS. At 25 years of age, she developed heart failure of both sides due to PR, TR and late-onset severe mitral stenosis (MS). The etiology of MS was uncertain. Owing to the patient’s condition, surgical options were considered to be extremely high risk. She was treated with optimal medical treatment as well as the occasional abdominal cavity drainage for recurrent ascites; however, she died of decompensated heart failure at 27 years of age.", + "summary_subclaims": [ + "The patient was a 25-year-old Japanese woman.", + "She was diagnosed with NS in adulthood.", + "She exhibited short stature.", + "She had minor facial dysmorphism.", + "She was diagnosed with PS at 1 year of age.", + "She underwent surgical valvuloplasty for PS at 6 years of age.", + "Her general condition became stable without specific medical treatment.", + "She discontinued regular medical follow-up for PS.", + "At 21 years of age, she developed acute decompensated heart failure.", + "The heart failure was mainly right-sided.", + "The heart failure was due to severe pulmonary regurgitation.", + "The heart failure was due to tricuspid regurgitation.", + "There was no evidence of HCM.", + "There was no evidence of PS recurrence.", + "She was clinically diagnosed with NS.", + "The diagnosis was based on the history of PS.", + "The diagnosis was based on characteristic physical features including short stature.", + "The diagnosis was based on webbed neck.", + "The diagnosis was based on hypertelorism.", + "At 25 years of age, she developed heart failure of both sides.", + "The heart failure was due to PR.", + "The heart failure was due to TR.", + "The heart failure was due to late-onset severe mitral stenosis.", + "The etiology of MS was uncertain.", + "Surgical options were considered to be extremely high risk.", + "She was treated with optimal medical treatment.", + "She had occasional abdominal cavity drainage for recurrent ascites.", + "She died of decompensated heart failure at 27 years of age." + ] + }, + { + "id": "multiclinsum_test_287_en.txt", + "fulltext": "A 45-year-old Chinese man was referred to our hospital for the treatment of right lumbago and odynuria, with no fever or gross hematuria. His past medical history was unremarkable and there was no history of any allergy or external trauma except a long working history in construction site. On admission, no abnormality was found in physical examination, Blood analyses revealed no leukocytosis (white blood cell count of 6.52 × 109/L), no elevation of eosinophils (eosinophils count of 0.44 × 109/L, eosinophil ratio Accounted for 6.7%). Renal function was normal (Serum creatinine level of 77.4 umol/L). Urinalysis confirmed no hematuria, leucocytes or protein. Ultrasound examination indicated the low echo on the right portion wall and the neck of the bladder, with dilation of the right lower ureter . Computed tomography showed no hydronephrsisa but a remarkable enhancing large mass that measured 5.0 cm × 2.3 cm located on the right portion of the bladder with undefined margin . Cystoscopy confirmed a huge follicle-like mass lesion on the right portion wall and the neck of the bladder with a broad base, in which blood vessels growing . Cystoscopic biopsy affirmed the chronic mucosal inflammation of bladder . For further treatment, diagnostic transurethral resection of the bladder was performed, the postoperative histopathological diagnosis was EC complicated with CG . After transurethral resection, antibiotics, glucocorticoids, and antihistamines were treated, the catheter was indwelled continuously until postoperative day 6. The patient recovered uneventfully and was discharged on postoperative day 8. Cystoscopy and eosinophils levels of blood and urine were required to be examined every 3 months during the first year. There was no evidence of recurrence followed up for 6 months.", + "fulltext_subclaims": [ + "The patient is a 45-year-old Chinese man.", + "He was referred for the treatment of right lumbago and odynuria.", + "He had no fever.", + "He had no gross hematuria.", + "His past medical history was unremarkable.", + "There was no history of any allergy.", + "There was no history of external trauma.", + "He had a long working history in construction site.", + "On admission, no abnormality was found in physical examination.", + "Blood analyses revealed no leukocytosis.", + "White blood cell count was 6.52 × 109/L.", + "Eosinophil count was 0.44 × 109/L.", + "Eosinophil ratio accounted for 6.7%.", + "Serum creatinine level was 77.4 umol/L.", + "Urinalysis confirmed no hematuria.", + "Ultrasound examination indicated low echo on the right portion wall and the neck of the bladder.", + "Computed tomography showed no hydronephrosis.", + "Computed tomography showed a remarkable enhancing large mass that measured 5.0 cm × 2.3 cm.", + "The mass was located on the right portion of the bladder.", + "The mass had undefined margin.", + "Cystoscopy confirmed a huge follicle-like mass lesion on the right portion wall and the neck of the bladder.", + "The mass had a broad base.", + "Cystoscopic biopsy affirmed chronic mucosal inflammation of bladder.", + "Diagnostic transurethral resection of the bladder was performed.", + "Postoperative histopathological diagnosis was EC complicated with CG.", + "Antibiotics, glucocorticoids, and antihistamines were treated.", + "The catheter was indwelled continuously until postoperative day 6.", + "The patient was discharged on postoperative day 8.", + "Cystoscopy and eosinophils levels of blood and urine were required to be examined every 3 months during the first year.", + "There was no evidence of recurrence followed up for 6 months." + ], + "summary": "A 45-year-old Chinese man was referred to our hospital for the treatment of right lumbago and odynuria. Ultrasound examination indicated the low echo on the right portion wall and the neck of the bladder. Computed tomography showed a remarkable enhancing large mass that measured 5.0 cm × 2.3 cm located on the right portion of the bladder with undefined margin. For further treatment, diagnostic transurethral resection of the bladder was performed, the postoperative histopathological diagnosis was EC complicated with CG. After transurethral resection, antibiotics, glucocorticoids, and antihistamines were treated. The patient recovered uneventfully and was discharged on postoperative day 8 without evidence of recurrence followed-up for 6 months.", + "summary_subclaims": [ + "The patient is a 45-year-old Chinese man.", + "The patient was referred to the hospital for the treatment of right lumbago and odynuria.", + "Ultrasound examination indicated low echo on the right portion wall and the neck of the bladder.", + "Computed tomography showed a remarkable enhancing large mass that measured 5.0 cm × 2.3 cm.", + "The mass was located on the right portion of the bladder.", + "The mass had undefined margins.", + "Diagnostic transurethral resection of the bladder was performed.", + "The postoperative histopathological diagnosis was EC complicated with CG.", + "After transurethral resection, antibiotics, glucocorticoids, and antihistamines were treated.", + "The patient was discharged on postoperative day 8.", + "There was no evidence of recurrence after 6 months of follow-up." + ] + }, + { + "id": "multiclinsum_test_3173_en.txt", + "fulltext": "A 32 year old woman in her first pregnancy had an anomaly scan at 23 weeks of gestation, at which the fetus was diagnosed to have a right sided CDH. The pregnancy was also complicated by polyhydramnios. There was a normal fetal echocardiogram. The initial observed to expected (O/E) lung area to head circumference ratio (LHR) was 41 %, which reduced to 17 % at 26 weeks of gestation. The mother was then referred at 26 weeks of gestation to our Fetal Medicine Unit where a fetal endoluminal tracheal occlusion (FETO) procedure was performed. FETO was performed by placing a thin walled flexible Teflon cannula loaded with a custom designed pyramidal trocar into the amniotic cavity through the abdominal and uterine walls and directed towards the fetal mouth. The trocar was then withdrawn and fetoscopic instruments, including an endoscope, inserted. The endoscope was introduced into the fetal mouth, pharynx and epiglottis and advanced through the vocal cords to identify the carina. The catheter was positioned to deliver the balloon just above the carina. The procedure was performed under local anaesthetic. Post-FETO, the observed to expected LHR O/E increased to 90 %. At 26 and 31 weeks of gestation, amnio drainage was undertaken because of the polyhydramnios (1700 and 2,700 mLs respectively were removed). No chromosomal anomalies were detected on genetic testing undertaken by microarray analysis. At 31+3 weeks of gestation, there was preterm, premature rupture of the membranes. An in-utero transfer was undertaken to our tertiary perinatal medical and surgical unit. The FETO balloon was punctured in-utero. The mother was given a complete corticosteroid course (two doses of betamethasone 24 h apart). She subsequently went into spontaneous preterm labour at 35+6 weeks of gestation. The O/E LHR immediately prior to delivery was 55 %.\n\nThe female infant was born by a forceps assisted vaginal delivery. The infant’s birthweight was 2.37 kg and the Apgar scores were five at one minute and six at five minutes respectively. A nasogastric tube was inserted and the baby was electively intubated at two minutes of age. She was initially ventilated on conventional mechanical ventilation (CMV) with a fraction of inspired oxygen concentration of 0.60, but due to a rising pressure requirement due to hypercarbia she was transferred to high-frequency oscillatory ventilation (HFOV) until day three. In total, she was ventilated for 25 days and remained oxygen dependent up till discharge to her local hospital at two months of age.\n\nA postnatal echocardiography showed a small intra-atrial communication and a PDA with bidirectional flow. Inhaled nitric oxide (iNO) was started on day one after birth due to a moderate pre-and post-ductal SpO2 difference of 5 %, but was able to be weaned after 48 h.\n\nThe chest radiograph demonstrated elevation of both hemidiaphragms with clear small lung fields. The appearance on the chest ultrasound (USS) and CT Chest suggested a CDH and a contralateral eventration, but with the possibility that there could be bilateral CDH. The abdominal radiograph demonstrated a double bubble and no gas in the distal bowel loops and hence duodenal atresia (DA) was suspected. DA was confirmed by barium follow-through. Surgical repair was undertaken on day six. Bilateral, type C posterolateral CDHs were noted with herniation of the liver on the right and the spleen, stomach, colon, and left lobe of liver on the left. Surgical repair included bilateral patch repair of the CDHs using ‘domed’ Goretex patches, as primary repair was not possible due to the size of the defects. Type one duodenal atresia (DA), with no malrotation, was identified and repaired with enterotomy and diamond duodenoduodenostomy. In order to prevent abdominal compartment syndrome, the abdomen was kept open using a Goretex patch. The patch was reduced on day 12 and the abdomen was closed on day 15.\n\nThe infant no longer required respiratory support by two months of age. At an outpatient follow-up appointment at four months of age, she continued to require no respiratory support. The infant was gaining weight along the second per centile for age having a combination of breast feeding and bolus nasogastric feeds (Infatrini) via a pump.", + "fulltext_subclaims": [ + "The patient is a 32 year old woman in her first pregnancy.", + "The fetus was diagnosed to have a right sided CDH.", + "The pregnancy was complicated by polyhydramnios.", + "The initial observed to expected (O/E) lung area to head circumference ratio (LHR) was 41 %.", + "The O/E LHR reduced to 17 % at 26 weeks of gestation.", + "A fetal endoluminal tracheal occlusion (FETO) procedure was performed.", + "FETO was performed by placing a thin walled flexible Teflon cannula loaded with a custom designed pyramidal trocar into the amniotic cavity.", + "The procedure was performed under local anaesthetic.", + "Post-FETO, the observed to expected LHR increased to 90 %.", + "Amnio drainage was undertaken at 26 and 31 weeks of gestation.", + "1700 mLs of amniotic fluid were removed at 26 weeks.", + "2,700 mLs of amniotic fluid were removed at 31 weeks.", + "No chromosomal anomalies were detected on genetic testing.", + "There was preterm, premature rupture of the membranes at 31+3 weeks of gestation.", + "An in-utero transfer was undertaken.", + "The FETO balloon was punctured in-utero.", + "The mother was given a complete corticosteroid course.", + "The mother received two doses of betamethasone 24 h apart.", + "She went into spontaneous preterm labour at 35+6 weeks of gestation.", + "The O/E LHR immediately prior to delivery was 55 %.", + "The infant was born by a forceps assisted vaginal delivery.", + "The infant’s birthweight was 2.37 kg.", + "The Apgar scores were five at one minute and six at five minutes.", + "A nasogastric tube was inserted.", + "The baby was electively intubated at two minutes of age.", + "She was initially ventilated on conventional mechanical ventilation.", + "She was transferred to high-frequency oscillatory ventilation until day three.", + "She was ventilated for 25 days.", + "She remained oxygen dependent up till discharge.", + "A postnatal echocardiography showed a small intra-atrial communication.", + "A PDA with bidirectional flow was noted.", + "Inhaled nitric oxide was started on day one after birth.", + "The chest radiograph demonstrated elevation of both hemidiaphragms.", + "The chest radiograph showed clear small lung fields.", + "The appearance on the chest ultrasound and CT Chest suggested a CDH and a contralateral eventration.", + "The abdominal radiograph demonstrated a double bubble.", + "No gas was seen in the distal bowel loops.", + "Duodenal atresia was suspected.", + "DA was confirmed by barium follow-through.", + "Surgical repair was undertaken on day six.", + "Bilateral, type C posterolateral CDHs were noted.", + "The right CDH herniated the liver.", + "The left CDH herniated the spleen, stomach, colon, and left lobe of liver.", + "Bilateral patch repair of the CDHs using Goretex patches was performed.", + "Type one duodenal atresia was identified.", + "The abdomen was kept open using a Goretex patch.", + "The patch was reduced on day 12.", + "The abdomen was closed on day 15.", + "The infant no longer required respiratory support by two months of age.", + "At four months of age, she continued to require no respiratory support.", + "The infant was gaining weight along the second percentile for age.", + "She had a combination of breast feeding and bolus nasogastric feeds via a pump." + ], + "summary": "The fetus was diagnosed with CDH at 23 weeks of gestation. Her mother was referred to our tertiary centre as the observed to expected lung-to-head ratio (O/E LHR) at 26 weeks of gestation was only 17 %. The fetus was treated by FETO with an increase in the LHR. The mother had polyhydramnios and underwent amniotic fluid drainage at 26 and 31 weeks of gestation. She had preterm, premature rupture of the membranes at 31+3 weeks of gestation. The FETO balloon was punctured and the mother received corticosteroids. She underwent spontaneous labour at 35+6 weeks of gestation when the LHR was 55 %. At birth, the female infant was electively intubated and ventilated. After successful stabilisation, surgical intervention was undertaken on day six when the defects were identified as bilateral, type C posterolateral CDHs. Bilateral patch repair of the CDHs was undertaken using ‘domed’ Goretex patches. Type one duodenal atresia (DA) was identified and repaired with enterotomy and diamond duodenoduodenostomy. There was partial and then full abdominal closure on days 12 and 15 respectively. The infant is now four months of age and requires no respiratory support.", + "summary_subclaims": [ + "The fetus was diagnosed with CDH at 23 weeks of gestation.", + "The observed to expected lung-to-head ratio (O/E LHR) at 26 weeks of gestation was only 17 %.", + "The fetus was treated by FETO with an increase in the LHR.", + "The mother had polyhydramnios and underwent amniotic fluid drainage at 26 and 31 weeks of gestation.", + "The mother had preterm, premature rupture of the membranes at 31+3 weeks of gestation.", + "The FETO balloon was punctured and the mother received corticosteroids.", + "The mother underwent spontaneous labour at 35+6 weeks of gestation when the LHR was 55 %.", + "At birth, the female infant was electively intubated and ventilated.", + "Surgical intervention was undertaken on day six when the defects were identified as bilateral, type C posterolateral CDHs.", + "Bilateral patch repair of the CDHs was undertaken using ‘domed’ Goretex patches.", + "Type one duodenal atresia (DA) was identified and repaired with enterotomy and diamond duodenoduodenostomy.", + "There was partial and then full abdominal closure on days 12 and 15 respectively.", + "The infant is now four months of age and requires no respiratory support." + ] + }, + { + "id": "multiclinsum_test_222_en.txt", + "fulltext": "A pregnant female, 34 years old, fourth gestation primiparity with current pregnancy estimated at 25 weeks of amenorrhea (WA) + 5 days, diabetic for 1 year, initially on oral antidiabetic drugs and then insulin therapy, hypertensive for 2 years on alpha methyldopa with a history of 3 miscarriages secondary to hypertensive peaks.\nDuring the 4th pregnancy, the patient was hospitalized at 20 WA in the endocrinology department for an etiological assessment of a hypertensive crisis at 180/110 mmHg associated with headaches, palpitations and hot flashes, without proteinuria or edema.\nIn front of these symptoms the diagnosis of a secretory neuroendocrine tumor is suspected, and a biological assessment including urinary and plasma catecholamines (metanephrine and normetanephrine) came back positive after eliminating other causes of secondary hypertension (nephropathy, renal artery stenosis or hyperaldosteronism), by renal evaluation, renal artery Doppler ultrasound and renin-angiotensin-aldosterone system exploration.\nUrinary dosages showed Metanephrines at 0.87 μmol/24 h (normal: 0.20–1), high Normetanephrine 24.14 μmol/24 h (normal: 0.4–2.10), While plasma dosages showed a Metanephrine level of 0.10 nmol/l (normal: < 0.33 nmol/l), a high level of Normetanephrine of 14.02 nmol (normal: <1.07 nmol/l). A thyroid workup was performed to rule out multiple endocrine neoplasia (MEN) returning normal: TSH 1.821 (normal: 0.340–5.330), anti-thyroperoxidase Ac < 0.8 IU/ml (normal <0.8).\nAbdominal-pelvic magnetic resonance imaging (MRI) showing an abdominal latero-aortic mass measuring 36 * 33 mm, corresponding to paraganglioma without any other obvious location .\nFor evaluation of maternal and fetal impact of the tumor:\nClinical examination including cardiovascular examination was normal. With an ECG that did not show rhythm or repolarization disorders or left ventricular hypertrophy.\nA standard biological workup (blood cell count, platelet count, hemostasis, blood ionogram, blood sugar-HBA1c, renal and hepatic function) was unremarkable.\nOn the obstetrical level, the clinical examination and the obstetrical ultrasound showed a monofetal pregnancy with no uterine or fetal abnormalities.\nAfter placing the patient on medical treatment and scheduling her for surgery, she was declared discharged with an ambulatory follow-up. At 25 weeks of amenorrhea; the patient was admitted to the operating room for laparoscopic removal of her paraganglioma.\nIn the operating room, considering the risk of perioperative morbidity related to severe per and postoperative hemodynamic instability (hypertensive crisis with sometimes rhythm disorder, coronary ischemia, left ventricular failure and hypotension secondary to a sudden release of catecholamines: to stress, painful stimulation due to intubation and incision, insufflation and manipulation of the tumor, abrupt and profound hypotension by sudden decrease of catecholamines at the fall of the part and venous clamping) and in front of the obligation to maintain a uterine perfusion and a good oxygenation of the fetus while avoiding maternal hypoxemia, the anesthetic management was as follows:Monitoring:\nHemodynamic: heart rate (HR), blood pressure (BP)\nRespiratory: respiratory rate, pulse oxygenometry (SpO2), capnography.\nECG and ST segment monitoring.\nCardiac output monitoring by pulse wave contour analysis.Left jugular venous line (for central venous pressure monitoring and vasoactive drugs perfusion) A right femoral arterial line with invasive arterial pressure monitoring Heating of the patient to prevent hypothermia\nAfter installation of the patient in left lateral decubitus proclive 30°, a pre-oxygenation was started, and an anesthetic induction was done by: 150mg Propofol 150μg Fentanyl, 50 mg Atracurium 50mg; intubation by tube No. 6.5 cm; maintenance of anesthesia was provided by: Propofol IVOC system with concentration of: 2ug/ml.\nMaintenance of etCO2 32–35 mmHG with insufflation pressures not exceeding 12 mmHG (8–10 mmHG) and close monitoring of blood glucose due to the risk of blood glucose imbalance.\nDuring tumor manipulation 3 episodes of arterial hypertension peaks were observed) (180/110–195/120-200/130 mmHg controlled by reinforcement of analgesia by reinjections of fentanyl 50 μg, deepening of anesthesia (Propofol concentrations 3.5 μg/ml), and administration of Nicardipine at 1–3 mg/h. Glycemia: varied between (0.98–1.21 g/l)\nThe tumor removal was followed by episodes of arterial hypotension (75 -45 mmHg), the conduct was to lighten the anesthesia, a volemic expansion with administration of norepinephrine at 2mg/h.\nFor paraganglioma extraction, the procedure lasted 2 hours [, ]., with an intraoperative diuresis of 500 ml and bleeding estimated at 80 cc.Norepinephrine infusion was gradually decreased and stopped just before extubation.\nThe patient was subsequently extubated with the following parameters BP: 140/75 mm hg HR: 90bpm, SaO2 100% and then sent to the intensive care unit for clinical and biological monitoring. Postoperative analgesia was started with paracetamol, nefopam and morphine. The antihypertensive treatment was resumed in front of the reappearance of hypertensive peaks.\nAn obstetrical evaluation with a foeto-placental ultrasound immediately and 6 hours after the operation returned normal with the presence of fetal heart activity .\n2 days after the postoperative hospitalization in the intensive care unit, the patient was weaned from all drugs with good evolution and was transferred to the visceral surgery department for further management.\nThis cases report follows SCARE guidelines 2020 .", + "fulltext_subclaims": [ + "The patient is a 34-year-old pregnant female.", + "She is in her fourth gestation and is a primipara.", + "The current pregnancy is estimated at 25 weeks of amenorrhea plus 5 days.", + "She has had diabetes for 1 year.", + "She was initially on oral antidiabetic drugs.", + "She was then on insulin therapy.", + "She has had hypertension for 2 years.", + "She is on alpha methyldopa.", + "She has a history of three miscarriages.", + "The miscarriages were secondary to hypertensive peaks.", + "She was hospitalized at 20 weeks of amenorrhea.", + "The hospitalization was in the endocrinology department.", + "The hospitalization was for an etiological assessment of a hypertensive crisis.", + "The hypertensive crisis occurred at 180/110 mmHg.", + "The hypertensive crisis was associated with headaches.", + "The hypertensive crisis was associated with palpitations.", + "The hypertensive crisis was associated with hot flashes.", + "There was no proteinuria.", + "There was no edema.", + "A secretory neuroendocrine tumor was suspected.", + "A biological assessment included urinary and plasma catecholamines.", + "Urinary metanephrines were 0.87 μmol/24 h.", + "The normal range for urinary metanephrines is 0.20–1 μmol/24 h.", + "Urinary normetanephrine was 24.14 μmol/24 h.", + "The normal range for urinary normetanephrine is 0.4–2.10 μmol/24 h.", + "Plasma metanephrine was 0.10 nmol/l.", + "The normal range for plasma metanephrine is <0.33 nmol/l.", + "Plasma normetanephrine was 14.02 nmol/l.", + "The normal range for plasma normetanephrine is <1.07 nmol/l.", + "Other causes of secondary hypertension were ruled out.", + "Abdominal-pelvic MRI showed an abdominal latero-aortic mass measuring 36 * 33 mm.", + "The mass corresponded to paraganglioma.", + "There was no other obvious location.", + "The patient was on medical treatment.", + "She was scheduled for surgery.", + "She was discharged with ambulatory follow-up.", + "At 25 weeks of amenorrhea, she was admitted to the operating room.", + "The surgery was laparoscopic removal of her paraganglioma.", + "The anesthetic management included hemodynamic monitoring.", + "The anesthetic management included respiratory monitoring.", + "The anesthetic management included ECG and ST segment monitoring.", + "The anesthetic management included cardiac output monitoring by pulse wave contour analysis.", + "A left jugular venous line was placed.", + "A right femoral arterial line was placed.", + "The patient was heated to prevent hypothermia.", + "Anesthetic induction included 150 mg propofol.", + "Anesthetic induction included 150 μg fentanyl.", + "Anesthetic induction included 50 mg atracurium.", + "Maintenance of anesthesia was provided by propofol IVOC system with concentration of 2 μg/ml.", + "Maintenance of etCO2 was 32–35 mmHg.", + "Insufflation pressures did not exceed 12 mmHg.", + "Three episodes of arterial hypertension peaks were observed during tumor manipulation.", + "The hypertension peaks were 180/110–195/120–200/130 mmHg.", + "The hypertension was controlled by reinforcement of analgesia with fentanyl 50 μg.", + "The hypertension was controlled by deepening of anesthesia with propofol concentrations 3.5 μg/ml.", + "The hypertension was controlled by administration of nicardipine at 1–3 mg/h.", + "Glycemia varied between 0.98–1.21 g/l.", + "The tumor removal was followed by episodes of arterial hypotension.", + "The hypotension ranged from 75–45 mmHg.", + "The hypotension was managed by lightening the anesthesia.", + "The hypotension was managed by volemic expansion.", + "The hypotension was managed by administration of norepinephrine at 2 mg/h.", + "The procedure lasted 2 hours.", + "Intraoperative diuresis was 500 ml.", + "Estimated intraoperative bleeding was 80 cc.", + "Norepinephrine infusion was gradually decreased and stopped before extubation.", + "The patient was extubated with BP 140/75 mmHg.", + "The patient was extubated with HR 90 bpm.", + "The patient was extubated with SaO2 100%.", + "An obstetrical evaluation with foeto-placental ultrasound was performed immediately after the operation.", + "An obstetrical evaluation with foeto-placental ultrasound was performed 6 hours after the operation.", + "The ultrasound showed normal fetal heart activity.", + "The patient was transferred to the intensive care unit.", + "Postoperative analgesia included paracetamol.", + "Postoperative analgesia included nefopam.", + "Postoperative analgesia included morphine.", + "Antihypertensive treatment was resumed in front of the reappearance of hypertensive peaks.", + "Two days after the postoperative hospitalization, the patient was weaned from all drugs.", + "The patient was transferred to the visceral surgery department.", + "This case report follows SCARE guidelines 2020." + ], + "summary": "In our article, we report the case of a patient with an estimated pregnancy at 25 weeks of amenorrhea (WA) with a history of 3 miscarriages related to atypical gravid hypertension.The treatment consisted of preoperative medical preparation followed by removal of the paraganglioma and postoperative monitoring. The maternal-fetal evolution was favorable.", + "summary_subclaims": [ + "The patient had an estimated pregnancy at 25 weeks of amenorrhea.", + "The patient had a history of 3 miscarriages.", + "The miscarriages were related to atypical gravid hypertension.", + "The treatment consisted of preoperative medical preparation.", + "The treatment included removal of the paraganglioma.", + "The treatment included postoperative monitoring.", + "The maternal-fetal evolution was favorable." + ] + }, + { + "id": "multiclinsum_test_853_en.txt", + "fulltext": "A 24-year-old man was transferred to our department with the complaint of dyspnea for 5 d after burnt lime aspiration after an accidental high fall.\nThe patient fell head down 5 d before admission from a height of 2 m into a truck of burnt lime and inhaled a large amount. He had severe dyspnea and was immediately admitted to a local hospital. Computed tomography (CT) showed a high-intensity mass in the right principle bronchus, and pneumomediastinum . Blood gas analysis demonstrated severe hypoxemia [partial pressure of oxygen (PaO2) 70 mmHg, fraction of inspired oxygen (FiO2) 50%]. Bronchoscopy and mechanical ventilation were carried out. Because of limited conditions, clearance of lime from the airway was not performed. The patient’s condition became more severe with additional symptoms such as disturbance of consciousness and fever (maximum 38.0°C). Follow-up CT at 1 d before admission showed a high-intensity mass in the right primary bronchus, right pulmonary atelectasis, right aeropleura, and pneumomediastinum. Blood gas analysis demonstrated severer hypoxemia (PaO2 48 mmHg, FiO2 100%). He then underwent closed drainage of the right thorax and was transferred to our department.\nThe patient had no history of illness.\nThe patient had no medical history.\nThe patient had dysphoria and was delirious. His body temperature was 39.5°C, respiratory rate 35–40 breaths/min, blood pressure 130/65 mmHg, pulse oxygen saturation (SpO2) 60% (FiO2 100%), missed respiratory sound in the right lung, crude respiratory sound in the left lung, no visible injury of the body skin, and conjunctival suffusion.\nBlood gas analysis demonstrated severer hypoxemia (PaO2 48 mmHg, FiO2 100%).\nCT showed a high-intensity mass in the right principle bronchus and pneumomediastinum . Follow-up CT showed a high-intensity mass in the right primary bronchus, right pulmonary atelectasis, right aeropleura, and pneumomediastinum.", + "fulltext_subclaims": [ + "The patient was a 24-year-old man.", + "He was transferred to the department with dyspnea for 5 d.", + "The dyspnea was after burnt lime aspiration.", + "The aspiration occurred after an accidental high fall.", + "He fell head down from a height of 2 m into a truck of burnt lime.", + "He inhaled a large amount of burnt lime.", + "Computed tomography showed a high-intensity mass in the right principle bronchus.", + "Computed tomography showed pneumomediastinum.", + "Blood gas analysis demonstrated severe hypoxemia.", + "The PaO2 was 70 mmHg.", + "The FiO2 was 50%.", + "Bronchoscopy and mechanical ventilation were carried out.", + "Clearance of lime from the airway was not performed.", + "The patient had disturbance of consciousness.", + "The patient had fever with a maximum of 38.0°C.", + "Follow-up CT showed a high-intensity mass in the right primary bronchus.", + "Follow-up CT showed right pulmonary atelectasis.", + "Follow-up CT showed right aeropleura.", + "Follow-up CT showed pneumomediastinum.", + "Blood gas analysis demonstrated severer hypoxemia.", + "The PaO2 was 48 mmHg.", + "The FiO2 was 100%.", + "The patient underwent closed drainage of the right thorax.", + "The patient had no history of illness.", + "The patient had no medical history.", + "The patient had dysphoria and was delirious.", + "His body temperature was 39.5°C.", + "His respiratory rate was 35–40 breaths/min.", + "His SpO2 was 60%.", + "The FiO2 was 100%.", + "Missed respiratory sound was noted in the right lung.", + "Crude respiratory sound was noted in the left lung.", + "No visible injury of the body skin was noted.", + "Conjunctival suffusion was noted." + ], + "summary": "We report an adult with a large amount of burnt lime aspiration. Because of delay in clearance of the inhaled lime in the trachea and bronchus at the local hospital, he suffered several severe complications, including complete occlusion of the right primary bronchus, aeropleura, aerodermectasia, pneumomediastinum, secondary infection and hypoxemia at 4 d after injury. After transferring to our department, bronchoscopy was immediately carried out to clear the lime in the major airway, using foreign body forceps, biopsy forceps, puncture needle, and hairbrush. The patient's condition recovered rapidly and at 3-months' follow-up, he demonstrated good recovery of the bronchus and lung parenchyma.", + "summary_subclaims": [ + "The patient had a large amount of burnt lime aspiration.", + "There was a delay in clearance of the inhaled lime in the trachea and bronchus at the local hospital.", + "The patient suffered complete occlusion of the right primary bronchus.", + "The patient had aeropleura.", + "The patient had aerodermectasia.", + "The patient had pneumomediastinum.", + "The patient had secondary infection.", + "The patient had hypoxemia at 4 d after injury.", + "Bronchoscopy was carried out to clear the lime in the major airway.", + "Foreign body forceps were used during bronchoscopy.", + "Biopsy forceps were used during bronchoscopy.", + "A puncture needle was used during bronchoscopy.", + "A hairbrush was used during bronchoscopy.", + "The patient's condition recovered rapidly.", + "At 3-months' follow-up, the patient demonstrated good recovery of the bronchus.", + "At 3-months' follow-up, the patient demonstrated good recovery of the lung parenchyma." + ] + }, + { + "id": "multiclinsum_test_2231_en.txt", + "fulltext": "A 48-year-old Bangladeshi gentleman was brought to the emergency room because of breathlessness and disorientation. He had been suffering from fever, cough and sputum production over the preceding 5 days. He had been receiving amoxicillin (orally 500 mg three times a day) and paracetamol (500 mg four times a day) without much benefit. He did not have significant medical history of note, except diabetes mellitus and was on vildagliptin–metformin combination (vildagliptin 50 mg and metformin 500 mg orally once daily).\nHe was febrile (temperature 38.9 °C), had altered conscious level (Glasgow Coma Scale E3V4M4, 11/15), low oxygen saturation (87% in room air), tachycardia (pulse 110/min), tachypnea (respiratory rate 38/min), normal blood pressure (115/75 mmHg), bi-basal crepitations and signs of meningeal irritation without any rash. Ocular fundi looked normal.\nRandom blood glucose was 8.9 mmol/L. Electrocardiography revealed sinus tachycardia, chest X-ray showed pulmonary oedema, computed tomography of head was normal. Arterial blood gas analysis showed type I respiratory failure. He was shifted to intensive care unit.\nHe had neutrophil leukocytosis (total white cell count 22,300/mm3, neutrophil 83%), high erythrocyte sedimentation rate (56 mm in 1st hour) and C-reactive protein (64 mg/L). Cerebrospinal fluid (CSF) was cloudy with high opening pressure, high protein (140.6 mg/dL, reference range 15–45 mg/dL) and low glucose (3.1 mmol/L, reference range 3.3–4.5 mmol/L) content, had high white cell counts with predominant neutrophils (1290 cells/mm3, polymorphs 90%). No micro-organism was identified in Gram-stain or acid fast bacilli (AFB) staining of CSF or cultures. Bacterial antigen test of CSF (done by Latex test to detect Streptococcus group B, H. influenza type B, S. pneumoniae, N. meningitides ABCY W135 and E. coli K1 antigens, Wellcogen™ Bacterial Antigen Kit, Remel Europe Ltd., UK) was positive for pneumococcus. Blood culture did not reveal any organism. Sputum microscopy revealed Gram positive cocci in long chains but culture did not reveal any organism. Urine routine examination showed red cells (5–8/high power field) and protein (+).\nTreatment consisted of ceftriaxone (2 g intravenously every 12 h), moxifloxacin (400 mg intravenously once daily), paracetamol, frusemide and insulin along with other supportive measures including oxygen. He became afebrile on fourth day and was transferred to general medical ward.\nHis assessment in ward showed a new regurgitant murmur in mitral area that radiated to left axilla. Transthoracic echocardiography revealed moderate mitral regurgitation but there was no vegetation. Trans-oesophageal echocardiography could not be done. Repeat chest X-ray revealed right middle lobe consolidation . Depending upon clinical manifestation, imaging, echocardiography, sputum, CSF and urine examination findings, he was diagnosed as having Austrian syndrome. He completed 4 weeks of intravenous antibiotic treatment, follow-up echocardiography after 6 weeks revealed trivial mitral regurgitation (Additional file ).", + "fulltext_subclaims": [ + "The patient is a 48-year-old Bangladeshi gentleman.", + "He was brought to the emergency room because of breathlessness and disorientation.", + "He had been suffering from fever, cough and sputum production over the preceding 5 days.", + "He had been receiving amoxicillin (orally 500 mg three times a day) and paracetamol (500 mg four times a day) without much benefit.", + "He did not have significant medical history of note, except diabetes mellitus.", + "He was on vildagliptin–metformin combination (vildagliptin 50 mg and metformin 500 mg orally once daily).", + "He was febrile (temperature 38.9 °C).", + "He had altered conscious level (Glasgow Coma Scale E3V4M4, 11/15).", + "He had low oxygen saturation (87% in room air).", + "He had tachycardia (pulse 110/min).", + "He had tachypnea (respiratory rate 38/min).", + "He had bi-basal crepitations.", + "He had signs of meningeal irritation.", + "Ocular fundi looked normal.", + "Random blood glucose was 8.9 mmol/L.", + "Electrocardiography revealed sinus tachycardia.", + "Chest X-ray showed pulmonary oedema.", + "Computed tomography of head was normal.", + "Arterial blood gas analysis showed type I respiratory failure.", + "He was shifted to intensive care unit.", + "He had neutrophil leukocytosis (total white cell count 22,300/mm3, neutrophil 83%).", + "Cerebrospinal fluid (CSF) was cloudy with high opening pressure.", + "CSF had high protein (140.6 mg/dL, reference range 15–45 mg/dL).", + "CSF had low glucose (3.1 mmol/L, reference range 3.3–4.5 mmol/L).", + "CSF had high white cell counts with predominant neutrophils (1290 cells/mm3, polymorphs 90%).", + "No micro-organism was identified in Gram-stain or acid fast bacilli (AFB) staining of CSF or cultures.", + "Bacterial antigen test of CSF was positive for pneumococcus.", + "Blood culture did not reveal any organism.", + "Sputum microscopy revealed Gram positive cocci in long chains.", + "Sputum culture did not reveal any organism.", + "Urine routine examination showed red cells (5–8/high power field) and protein (+).", + "Treatment consisted of ceftriaxone (2 g intravenously every 12 h).", + "Treatment consisted of moxifloxacin (400 mg intravenously once daily).", + "He became afebrile on fourth day.", + "He was transferred to general medical ward.", + "He had a new regurgitant murmur in mitral area that radiated to left axilla.", + "Transthoracic echocardiography revealed moderate mitral regurgitation.", + "There was no vegetation.", + "Trans-oesophageal echocardiography could not be done.", + "Repeat chest X-ray revealed right middle lobe consolidation.", + "He was diagnosed as having Austrian syndrome.", + "He completed 4 weeks of intravenous antibiotic treatment.", + "Follow-up echocardiography after 6 weeks revealed trivial mitral regurgitation." + ], + "summary": "We report the case history of a middle aged Bangladeshi diabetic man, who had fever, cough, shortness of breath and altered mentation. He had tachycardia, bi-basal lung crepitations, new cardiac murmurs and meningism. Diagnostic work-up revealed Austrian syndrome. Because of the rarity of the condition, this case is reported.", + "summary_subclaims": [ + "The patient was a middle aged Bangladeshi diabetic man.", + "The patient had fever.", + "The patient had cough.", + "The patient had shortness of breath.", + "The patient had altered mentation.", + "The patient had tachycardia.", + "The patient had bi-basal lung crepitations.", + "The patient had new cardiac murmurs.", + "The patient had meningism.", + "Diagnostic work-up revealed Austrian syndrome.", + "The condition is rare.", + "This case is reported." + ] + }, + { + "id": "multiclinsum_test_630_en.txt", + "fulltext": "A 6-year-old Greek boy was referred to our hospital with acute abdominal pain, fever, and vomiting that had started 30 h earlier. On presentation, he was hemodynamically stable and well-hydrated. His abdominal examination revealed right lower quadrant pain on palpation and a positive McBurney sign with signs of peritoneal irritation. His hemoglobin was 12.2 g/dl (normal range 12–15 g/dl), his hematocrit was 34.6 % (normal range 36–44 %), his mean corpuscular volume was 72.7 (normal range 77–89), his mean corpuscular hemoglobin was 24.7 (normal range 25–31), his leukocyte count was 15,110/μl (normal range 5000–13,500/μl), his platelet count was 279,000/μl (normal range 200,000–400,000/μl), and his C-reactive protein level was 3.81 mg/dl (normal range <0.51 mg/dl). His electrolyte and coagulation profiles were within normal ranges.\nAs the boy’s history and physical examination referred to acute appendicitis, ultrasound was performed. Ultrasonography showed a well-defined, hypoechogenic solid mass measuring 6 × 2 cm in the right iliac fossa . Other abdominal structures, including the appendix, liver, and kidneys, were normal. Because of the complex nature of the lesion, computed tomography was also performed. A computed tomographic scan showed a solid mass measuring 6 × 2.4 cm in the right abdomen. The mass was in contact at one end with the ascending colon and at the other end with the small bowel . Imaging findings excluded the presence of acute appendicitis or Meckel’s diverticulum. Emergency laparoscopic exploration was performed using a 10-mm trocar placed in the umbilicus with two accessory trocars in the left and right lower quadrants (5 mm). A pediculated solid mass attached to the antimesenteric edge of the ileum and 8 cm proximal to the ileocecal valve was found. It was covered by inflammatory omentum. It appeared ischemic due to torsion at the level of the pediculated attachment to the ileum. The inflammatory part of the omentum covering the mass was laparoscopically resected free, and the mass with the adjacent ileal loop was exteriorized through a circumbilical incision at the site of the umbilical opening and easily separated from the ileal edge . The ileal wall was normal .\nThe histopathologic diagnosis was made by using hematoxylin and eosin-stained slides and immunohistochemistry. The histological examination revealed a circumscribed mesenchymal myofibroblastic lesion with a focal mesothelial lining and a considerable vascular component showing excessive hemorrhage and heterogeneous ischemic necrosis. The lesion was composed of clustered and dispersed fibroblastic spindle cells with eosinophilic cytoplasm and a nucleus with fine chromatin without any considerable nuclear atypia or mitotic activity. Characteristic features were the myxoid configuration of the lesion, the variable hyalinization, and the moderate inflammatory infiltrate composed mainly of plasma cells and lymphocytes.\nImmunohistochemistry of the spindle cells showed focal expression of desmin (clone D33), cytokeratins 8 and 18, and pan-keratin AE1/AE3, while there was no detection of smooth muscle actin (SMA), myogenin/Myf-4, CD34, S100, c-kit/CD117, epithelial membrane antigen, β-catenin, Bcl-2 protein, melanosome-associated antigen/HMB45, or anaplastic lymphoma kinase (ALK)-1/p80. Although the described immunophenotype is not entirely diagnostic of a specific entity, it may be encountered in OMMH, which is considered a variant of IMT, though this is a subject of debate.\nThe patient’s laboratory values improved dramatically after surgery, and he had an uneventful postoperative course. He was discharged from the hospital on the fourth postoperative day. No evidence of recurrence was noted during 2 years of follow-up, and the patient remains under clinical surveillance.", + "fulltext_subclaims": [ + "The patient was a 6-year-old Greek boy.", + "He was referred to the hospital with acute abdominal pain, fever, and vomiting that had started 30 hours earlier.", + "On presentation, he was hemodynamically stable.", + "His abdominal examination revealed right lower quadrant pain on palpation.", + "He had a positive McBurney sign.", + "There were signs of peritoneal irritation.", + "His hemoglobin was 12.2 g/dl.", + "The normal range for hemoglobin is 12–15 g/dl.", + "His hematocrit was 34.6 %.", + "The normal range for hematocrit is 36–44 %.", + "His mean corpuscular volume was 72.7.", + "The normal range for mean corpuscular volume is 77–89.", + "His mean corpuscular hemoglobin was 24.7.", + "The normal range for mean corpuscular hemoglobin is 25–31.", + "His leukocyte count was 15,110/μl.", + "The normal range for leukocyte count is 5000–13,500/μl.", + "His platelet count was 279,000/μl.", + "The normal range for platelet count is 200,000–400,000/μl.", + "His C-reactive protein level was 3.81 mg/dl.", + "The normal range for C-reactive protein is <0.51 mg/dl.", + "Ultrasonography showed a well-defined, hypoechogenic solid mass measuring 6 × 2 cm in the right iliac fossa.", + "Computed tomography showed a solid mass measuring 6 × 2.4 cm in the right abdomen.", + "The mass was in contact at one end with the ascending colon.", + "The mass was in contact at the other end with the small bowel.", + "Imaging findings excluded the presence of acute appendicitis.", + "Imaging findings excluded the presence of Meckel’s diverticulum.", + "Emergency laparoscopic exploration was performed.", + "A pediculated solid mass attached to the antimesenteric edge of the ileum was found.", + "The mass was 8 cm proximal to the ileocecal valve.", + "The mass was covered by inflammatory omentum.", + "The mass appeared ischemic due to torsion at the level of the pediculated attachment to the ileum.", + "The inflammatory part of the omentum covering the mass was laparoscopically resected free.", + "The mass with the adjacent ileal loop was exteriorized through a circumbilical incision.", + "The ileal wall was normal.", + "The histopathologic diagnosis was made by using hematoxylin and eosin-stained slides and immunohistochemistry.", + "The histological examination revealed a circumscribed mesenchymal myofibroblastic lesion.", + "The lesion had a focal mesothelial lining.", + "The lesion had a considerable vascular component showing excessive hemorrhage.", + "The lesion had heterogeneous ischemic necrosis.", + "The lesion was composed of clustered and dispersed fibroblastic spindle cells with eosinophilic cytoplasm.", + "The nucleus of the spindle cells had fine chromatin.", + "There was no considerable nuclear atypia.", + "There was no mitotic activity.", + "The lesion had a myxoid configuration.", + "The lesion had variable hyalinization.", + "The lesion had a moderate inflammatory infiltrate composed mainly of plasma cells and lymphocytes.", + "Immunohistochemistry of the spindle cells showed focal expression of desmin (clone D33).", + "Immunohistochemistry showed focal expression of cytokeratins 8 and 18.", + "Immunohistochemistry showed focal expression of pan-keratin AE1/AE3.", + "There was no detection of smooth muscle actin (SMA).", + "There was no detection of myogenin/Myf-4.", + "There was no detection of CD34.", + "There was no detection of S100.", + "There was no detection of c-kit/CD117.", + "There was no detection of epithelial membrane antigen.", + "There was no detection of β-catenin.", + "There was no detection of Bcl-2 protein.", + "There was no detection of melanosome-associated antigen/HMB45.", + "There was no detection of anaplastic lymphoma kinase (ALK)-1/p80.", + "The described immunophenotype is not entirely diagnostic of a specific entity.", + "The described immunophenotype may be encountered in OMMH.", + "OMMH is considered a variant of IMT.", + "This is a subject of debate.", + "The patient’s laboratory values improved dramatically after surgery.", + "He had an uneventful postoperative course.", + "He was discharged from the hospital on the fourth postoperative day.", + "No evidence of recurrence was noted during 2 years of follow-up.", + "The patient remains under clinical surveillance." + ], + "summary": "A 6-year-old Greek boy was referred to our hospital with acute abdominal pain mimicking appendicitis. Ultrasound and computed tomography revealed a solid mass in the abdomen. The patient underwent laparoscopic resection of the tumor, and histopathology and immunohistochemical analysis favored an omental-mesenteric myxoid hamartoma, which is a variant of an inflammatory myofibroblastic tumor. The patient's postoperative course was uneventful, and he has been asymptomatic during follow-up.", + "summary_subclaims": [ + "A 6-year-old Greek boy was referred to our hospital with acute abdominal pain mimicking appendicitis.", + "Ultrasound and computed tomography revealed a solid mass in the abdomen.", + "The patient underwent laparoscopic resection of the tumor.", + "Histopathology and immunohistochemical analysis favored an omental-mesenteric myxoid hamartoma.", + "An omental-mesenteric myxoid hamartoma is a variant of an inflammatory myofibroblastic tumor.", + "The patient's postoperative course was uneventful.", + "The patient has been asymptomatic during follow-up." + ] + }, + { + "id": "multiclinsum_test_2348_en.txt", + "fulltext": "A 73-year-old male presented to the emergency department with complaints of fevers peaking at 104 °F, chills, and rigors for 4–5 days. The patient's past medical history was significant for oropharyngeal squamous cell carcinoma treated with resection and adjuvant radiotherapy, hypopharyngeal squamous cell carcinoma treated with laryngopharyngectomy and neck dissection with tracheostomy, prostate cancer, and melanoma. Per the patient, he did not have any pets and did not have any other zoonotic exposure. The patient resided in the city (urban environment) and had retired from his job as a construction worker 15 years earlier. The patient reported that several days prior to the onset of symptoms, he had started a new chemotherapy regimen for his squamous cell carcinoma. He also reported a chronic intermittent productive cough that was old. The rest of the patient's review of systems was negative.\nThe patient's vital signs upon admission were as follows: temperature of 39.2 °C, heart rate of 109 beats/minute, blood pressure of 99/70 mmHg, and respiratory rate of 26 breaths/minute, with a SpO2 of 100%. Physical examination yielded a gentleman who was lying comfortably in bed and was warm to the touch, with a tracheostomy in place. The tracheostomy appeared clean, non-erythematous, and free of discharge. Pulmonary auscultation revealed breath sounds decreased in the right lung, as well as coarse crackles.\nLab results were as follows: white blood cell count 13.4 K/μL with 88% neutrophils and 9% bands, hemoglobin 12.2 g/dL, platelet count 114 K/μL, albumin 2.9 g/dL, and lactic acid 1.4 mmol/L. A urinalysis was performed, which was unremarkable. A chest x-ray showed a new right mid lung nodule and right basilar opacity suggestive of pneumonia or mass.\nBlood cultures were drawn, and the patient started empiric antibiotic therapy with intravenous cefepime, vancomycin, and metronidazole, which was subsequently switched to ampicillin/sulbactam, for presumed sepsis secondary to pneumonia. Two of the four blood culture bottles grew P. multocida sensitive to amoxicillin/clavulanic acid, tetracycline, and penicillin G. A subsequent computed tomography scan of the chest showed multiple lung masses which were suspicious for metastases. A transthoracic echocardiogram showed no signs of infective endocarditis. After consultation with pulmonology and infectious disease, antibiotics were switched to amoxicillin/clavulanic acid 875 mg–125 mg twice daily by mouth. Lower respiratory cultures were done which showed gram negative bacteria and later showed Pasteurella. This was considered consistent with blood cultures and the source for infection was considered secondary to obstructive pneumonia due to multiple lung masses. Speciation was not available from the lower respiratory cultures. Nasopharyngeal swab was not done.\nThe patient continued to improve, and the repeat blood cultures after 48 h were negative. As the patient did not have any new cardiovascular abnormalities and repeat blood cultures were negative with medical therapy, infectious disease did not recommend a transesophageal echocardiogram. The patient was discharged with amoxicillin/clavulanic acid 875 mg–125 mg twice daily by mouth to complete a 14-day course.", + "fulltext_subclaims": [ + "A 73-year-old male presented to the emergency department with complaints of fevers peaking at 104 °F, chills, and rigors for 4–5 days.", + "The patient's past medical history was significant for oropharyngeal squamous cell carcinoma treated with resection and adjuvant radiotherapy.", + "The patient had hypopharyngeal squamous cell carcinoma treated with laryngopharyngectomy and neck dissection with tracheostomy.", + "The patient had prostate cancer.", + "The patient had melanoma.", + "The patient did not have any pets.", + "The patient did not have any other zoonotic exposure.", + "The patient resided in the city.", + "The patient had retired from his job as a construction worker 15 years earlier.", + "The patient reported that several days prior to the onset of symptoms, he had started a new chemotherapy regimen for his squamous cell carcinoma.", + "The patient reported a chronic intermittent productive cough that was old.", + "The rest of the patient's review of systems was negative.", + "The patient's temperature upon admission was 39.2 °C.", + "The patient's heart rate upon admission was 109 beats/minute.", + "The patient's blood pressure upon admission was 99/70 mmHg.", + "The patient's respiratory rate upon admission was 26 breaths/minute.", + "The patient's SpO2 upon admission was 100%.", + "Physical examination showed a gentleman who was lying comfortably in bed and was warm to the touch.", + "The tracheostomy appeared clean, non-erythematous, and free of discharge.", + "Pulmonary auscultation revealed breath sounds decreased in the right lung.", + "Pulmonary auscultation revealed coarse crackles.", + "Lab results showed a white blood cell count of 13.4 K/μL.", + "Lab results showed 88% neutrophils.", + "Lab results showed 9% bands.", + "Lab results showed hemoglobin of 12.2 g/dL.", + "Lab results showed platelet count of 114 K/μL.", + "Lab results showed albumin of 2.9 g/dL.", + "Lab results showed lactic acid of 1.4 mmol/L.", + "A urinalysis was performed, which was unremarkable.", + "A chest x-ray showed a new right mid lung nodule.", + "A chest x-ray showed a right basilar opacity suggestive of pneumonia or mass.", + "Blood cultures were drawn.", + "The patient was started on empiric antibiotic therapy with intravenous cefepime, vancomycin, and metronidazole.", + "The antibiotic therapy was switched to ampicillin/sulbactam.", + "Two of the four blood culture bottles grew P. multocida.", + "P. multocida was sensitive to amoxicillin/clavulanic acid.", + "P. multocida was sensitive to tetracycline.", + "P. multocida was sensitive to penicillin G.", + "A computed tomography scan of the chest showed multiple lung masses suspicious for metastases.", + "A transthoracic echocardiogram showed no signs of infective endocarditis.", + "Antibiotics were switched to amoxicillin/clavulanic acid 875 mg–125 mg twice daily by mouth.", + "Lower respiratory cultures showed gram negative bacteria.", + "Lower respiratory cultures later showed Pasteurella.", + "The source for infection was considered secondary to obstructive pneumonia due to multiple lung masses.", + "Speciation was not available from the lower respiratory cultures.", + "The patient continued to improve.", + "Repeat blood cultures after 48 h were negative.", + "Infectious disease did not recommend a transesophageal echocardiogram.", + "The patient was discharged with amoxicillin/clavulanic acid 875 mg–125 mg twice daily by mouth.", + "The patient was to complete a 14-day course." + ], + "summary": "A 73-year-old patient with history significant for multiple malignancies including lung cancer presented to the emergency department with a fever, chills, and rigor. Patient denied any zoonotic exposure and did not have any soft tissue or skin structure infection. Laboratory testing and imaging revealed sepsis secondary to pneumonia and further lower respiratory cultures grew Pasteurella. Subsequent laboratory cultures indicated P. multocida bacteremia.", + "summary_subclaims": [ + "The patient is a 73-year-old.", + "The patient has a history of multiple malignancies.", + "The patient has lung cancer.", + "The patient presented to the emergency department with fever, chills, and rigor.", + "The patient denied any zoonotic exposure.", + "The patient did not have any soft tissue or skin structure infection.", + "Laboratory testing and imaging revealed sepsis secondary to pneumonia.", + "Lower respiratory cultures grew Pasteurella.", + "Subsequent laboratory cultures indicated P. multocida bacteremia." + ] + }, + { + "id": "multiclinsum_test_2485_en.txt", + "fulltext": "A 45-year-old male patient, without any past medical conditions, presented with a severe burning sensation on the hallux, 2nd, 3rd digits, and dorsum of the right foot. The patient, who works in a chemical plant, was replacing a worn-out flowmeter connected to the EO tank. The patient was not wearing personal protective equipment (PPE), such as chemical-resistant clothing and shoes. According to the Material Safety Data Sheets, EO is supplied through an automatic isolation line. During the incident at 2 PM, a large amount of water mixed with EO solution spilled on his right shoe. The patient did not experience any immediate symptoms and continued working with the wet shoe until approximately 5:30 PM. He returned home around 7 PM (approximately 5 hours after the exposure) and took a shower, effectively decontaminating the region. The next morning, the patient woke up to a severe burning sensation and pain in the dorsum of the right foot and proximal area of the digits. He discovered desquamation, redness, and oozing. The patient then presented to a nearby hospital .\nThe patient did not provide any specific family history and was not under treatment for any disease or condition. He reported a smoking habit (10 pack-years) with occasional social alcohol consumption.\nThe patient had worked in restaurants since his mid-20s. Since 2013, he had been employed at a chemical plant for trial runs of facilities and indicator system maintenance and repair. In 2018, he started to work in production of basic petrochemicals such as surfactants and concrete hardeners. He was responsible for the EO supply from the ingredient tank to the production line, replacement of indicator systems, and facility maintenance. Typically, there is no risk of EO exposure, as it is supplied through an automatic isolated pipeline, but workers may be exposed during the replacement of indicator systems.\nThe patient had stable vital signs within the normal limits and was alert. However, the patient appeared acutely ill at presentation and had subcutaneous tissue damage on the right dorsum of the foot and digits, with severe redness and dark pink dermal surfaces, serosanguineous exudates, blisters, and desquamation . The burn area was calculated to be 3.5% of the total body surface area. He did not report dyspnea and had clear breathing sounds upon auscultation.\nHematological analyses (complete blood count, blood chemistry), urinalysis, and plain chest radiograph performed at the emergency department were all within the normal limits.\nThe area was irrigated and disinfected. Topical antibiotics, silver sulfadiazine, was applied to unhealed burn wounds to protect the burn from becoming infected and the patient was followed-up in the outpatient clinic for 4 weeks. Normal skin was restored without any defects, and at the 9-month follow-up, there were no notable findings in the area other than hyperpigmentation . At a general health assessment 9 months after the incident, the patient reported reduced sensation in the right foot. After an outpatient consultation at our department of occupational and environmental health, he was referred to hematology-oncology, pulmonology, and neurology. There were no abnormal findings in the peripheral blood smear, bronchial provocation test, nerve conduction study, and electromyography. Follow-up was therefore concluded.\nFor this study, we obtained approval from the Institutional Review Board (IRB) of Dankook University Hospital (IRB No. 2021-05-009).", + "fulltext_subclaims": [ + "The patient is a 45-year-old male.", + "The patient had no past medical conditions.", + "The patient presented with a severe burning sensation on the hallux, 2nd, 3rd digits, and dorsum of the right foot.", + "The patient works in a chemical plant.", + "The patient was replacing a worn-out flowmeter connected to the EO tank.", + "The patient was not wearing personal protective equipment (PPE), such as chemical-resistant clothing and shoes.", + "EO is supplied through an automatic isolation line according to the Material Safety Data Sheets.", + "A large amount of water mixed with EO solution spilled on his right shoe during the incident at 2 PM.", + "The patient did not experience any immediate symptoms.", + "The patient continued working with the wet shoe until approximately 5:30 PM.", + "The patient returned home around 7 PM.", + "The patient took a shower, effectively decontaminating the region.", + "The next morning, the patient woke up to a severe burning sensation and pain in the dorsum of the right foot and proximal area of the digits.", + "The patient discovered desquamation, redness, and oozing.", + "The patient had subcutaneous tissue damage on the right dorsum of the foot and digits.", + "The burn area was calculated to be 3.5% of the total body surface area.", + "Hematological analyses, urinalysis, and plain chest radiograph performed at the emergency department were all within the normal limits.", + "Topical antibiotics, silver sulfadiazine, was applied to unhealed burn wounds.", + "The patient was followed-up in the outpatient clinic for 4 weeks.", + "Normal skin was restored without any defects.", + "At the 9-month follow-up, there were no notable findings in the area other than hyperpigmentation.", + "The patient reported reduced sensation in the right foot.", + "The patient was referred to hematology-oncology, pulmonology, and neurology.", + "There were no abnormal findings in the peripheral blood smear, bronchial provocation test, nerve conduction study, and electromyography.", + "Follow-up was therefore concluded.", + "For this study, we obtained approval from the Institutional Review Board (IRB) of Dankook University Hospital (IRB No. 2021-05-009)." + ], + "summary": "A 45-year-old man presented with painful exudative lesions on the right foot after working with ethylene oxide solution in a chemical plant. The patient stated that the solution had percolated through his shoe and he had not washed the solution off for 5 hours. Symptoms, including pain and erythema, appeared after a delay of more than 12 hours from the time of initial exposure. The skin of his right foot was irrigated with saline and covered with a wet dressing and topical antibiotics in the emergency department. The patient was followed up for 4 weeks at an outpatient clinic.", + "summary_subclaims": [ + "The patient is a 45-year-old man.", + "He presented with painful exudative lesions on the right foot.", + "The lesions occurred after working with ethylene oxide solution in a chemical plant.", + "The solution had percolated through his shoe.", + "He had not washed the solution off for 5 hours.", + "Symptoms, including pain and erythema, appeared after a delay of more than 12 hours from the time of initial exposure.", + "The skin of his right foot was irrigated with saline in the emergency department.", + "The foot was covered with a wet dressing and topical antibiotics in the emergency department.", + "The patient was followed up for 4 weeks at an outpatient clinic." + ] + }, + { + "id": "multiclinsum_test_2457_en.txt", + "fulltext": "A 34-year-old man presented to the outpatient department with a 6-month history of neck pain and bilateral upper limb radiation. His neck pain had increased progressively. At the time of presentation, his neck pain visual analog scale (VAS) score was 7/10, and his neck disability index (NDI) score was 30. He had received non-steroidal anti-inflammatories for more than 6 months and an epidural injection elsewhere with minimal relief from symptoms. On physical examination, power in all limbs was 5/5 as per the medical research council grading, and deep tendon reflexes were normal, too. The past, personal, addiction, or familial history was not significant. The magnetic resonance images showed a single fluid-containing lesion with a hyperintense zone at the C5–6 levels with central disc herniation . After adequate counseling with an explanation of the pros and cons of the procedure and its probable complications, the informed consent of the patient was taken, and the patient was planned for the navigable ablation decompression treatment (L-DISQ) procedure.", + "fulltext_subclaims": [ + "A 34-year-old man presented to the outpatient department with a 6-month history of neck pain and bilateral upper limb radiation.", + "The patient's neck pain had increased progressively.", + "At the time of presentation, his neck pain visual analog scale (VAS) score was 7/10.", + "At the time of presentation, his neck disability index (NDI) score was 30.", + "He had received non-steroidal anti-inflammatories for more than 6 months.", + "He had an epidural injection elsewhere.", + "He had minimal relief from symptoms.", + "On physical examination, power in all limbs was 5/5 as per the medical research council grading.", + "The past, personal, addiction, or familial history was not significant.", + "The magnetic resonance images showed a single fluid-containing lesion with a hyperintense zone at the C5–6 levels.", + "The magnetic resonance images showed central disc herniation.", + "After adequate counseling with an explanation of the pros and cons of the procedure and its probable complications, the informed consent of the patient was taken.", + "The patient was planned for the navigable ablation decompression treatment (L-DISQ) procedure." + ], + "summary": "A 34-year-old man presented to the outpatient department with a 6-month history of neck pain and bilateral upper limb radiation. His neck pain had increased progressively. At the time of presentation, his neck pain visual analog scale score was 7/10, and his neck disability index score was 30. The magnetic resonance images showed a single fluid-containing lesion with a hyperintense zone at the C4-5 levels with central disc herniation. The patient was successfully treated with the navigable ablation decompression treatment (L-DISQ) procedure.", + "summary_subclaims": [ + "A 34-year-old man presented to the outpatient department with a 6-month history of neck pain and bilateral upper limb radiation.", + "The patient's neck pain had increased progressively.", + "At the time of presentation, his neck pain visual analog scale score was 7/10.", + "The magnetic resonance images showed a single fluid-containing lesion with a hyperintense zone at the C4-5 levels.", + "The patient was successfully treated with the navigable ablation decompression treatment (L-DISQ) procedure." + ] + }, + { + "id": "multiclinsum_test_3105_en.txt", + "fulltext": "In January 2011, a 40-year-old woman was presented at our emergency department with a six-day history of fever up to 38.1 degrees Celsius every evening and with exertional retrosternal chest pain. She reported no other symptoms like dyspnea, abdominal pain, urinary, or stool abnormalities. Past medical history revealed an appendectomy at the age of 12, a caesarean section in 1993 and a thyroidectomy in November 2010 due to Graves’ disease. Approximately 5 months prior to presentation (August 2010), the patient had been on holiday in Hurghada, Egypt. Her long-term medication included levothyroxin, esomeprazole, and tizanidin. Her primary care physician had prescribed amoxicillin/clavulanic acid the day before presentation at our department. The patient worked as a nurse in a nursing home for the elderly. She smoked 15 cigarettes per day (15 pack years), occasionally drank alcohol, and had an allergy to house dust mites. Her cardiovascular risk factors were smoking, hypercholesterolemia, and a family history of myocardial infarction.\n\nThe patient was in a good general condition. On arrival, temperature was 36.9° Celsius, blood pressure 150 over 90 mmHg, heart rate 130 beats per minute, and oxygen saturation 97% with ambient air. Auscultation and percussion of lung and heart were unremarkable. The abdomen showed no resistance or tenderness. No peripheral edema was observed. Results of a basic neurological examination were unremarkable and the skin was normal.\n\nAn electrocardiogram (ECG) revealed sinus tachycardia with a heart rate of 120 beats per minute, normal axis, and slight T-wave inversion in leads V3-V6. The white blood cell count was 13.2 G/l with 4% (0.5 G/l) eosinophils, hemoglobin 13.6 g/dl, platelet count 176 G/l. Levels of serum creatinine, blood urea nitrogen and electrolytes were normal. The concentrations of gamma glutamyltransferase (54 U/l) and alkaline phosphatase (122 U/l) were slightly elevated. C-reactive protein (CRP, 6.11 mg/dl), high sensitive Troponin-T (hs TnT, 67 pg/ml) and D-Dimer (2.06 mg/l) were also elevated (Table 1). Chest x-ray was unremarkable and computed tomography angiography showed no signs of pulmonary embolism. Transthoracic echocardiogram was without pathological findings. In particular, it revealed normal right and left ventricular function, no wall motion abnormalities and no evidence of valve disease or pericardial effusion. Based on the history, laboratory result and imaging findings, (peri-) myocarditis was suspected and the patient was admitted for observation and symptomatic treatment with aminosalicylic acid and ibuprofen.\n\nOn day two of hospitalization, the patient had no more complaints, cardiac enzymes and CRP decreased, and on day three the patient was discharged. Further diagnostic procedures included blood culture, immunology (anti-nuclear antibodies with subsets, anti-neutrophil cytoplasmic antibodies, [ANCA]), virus serology for typical cardiotropic viruses, antibodies (complement-fixation test) against mycoplasma, coxiella burnetii (Q-fever), chlamydia psittaci (ornithosis) and interferon-γ release assays were negative, except for perinuclear anti-neutrophil cytoplasmic antibodies (p-ANCA) which were elevated to 47 U/ml (0–20).\n\nEight months later, in September 2011, the patient was re-hospitalized with chest pain for 1 week, dyspnea on minimal exertion (New York Heart Association [NYHA] functional class IV), which had developed within 4 days, and a new echocardiographic finding of severe mitral regurgitation. Medication comprised levothyroxin, bisoprolol and simvastatin. On examination, the temperature was 36.9° Celsius, blood pressure 100 over 75 mmHg, heart rate 99 beats per minute and oxygen saturation 97% (pulse oximetry) with ambient air. Auscultation and percussion of lung and heart were unremarkable and the abdomen showed no resistance or tenderness. No peripheral edema was observed. Laboratory results showed elevated white blood-cell count 14.7 G/l with 6% (0.8 G/l) eosinophilic, NT-proBNP (3697 pg/ml), LDH (375 U/l) and CRP (1.47 mg/dl). Hs-TnT and creatine kinase were normal.\n\nOn ECG a new P-mitrale was detected (see Additional file 1). Transthoracic and transesophageal echocardiogram showed a hyperdynamic left ventricle with preserved left ventricular ejection fraction without any regional wall motion abnormalities and dilated left and right atria. The left ventricular apical and lateral wall were thickened while the interventricular septum was normal. Doppler recordings of mitral valve inflow showed a restrictive filling pattern with severe mitral regurgitation (see Additional file 2). Further aortic and tricuspid regurgitation as well as significant elevated systolic pulmonary artery pressure were observed in the absence of pericardial effusion.\n\nCoronary angiography was unremarkable but invasive hemodynamic evaluation showed postcapillary pulmonary hypertension (mean pulmonary artery pressure 42 mmHg) with markedly elevated left ventricular filling pressures (LV end-diastolic pressure 39 mmHg) and reduced cardiac index (1.74 L/min/m2). Left ventriculography showed apical contrast dye sparing.\n\nCMR imaging confirmed severe mitral regurgitation and revealed a mildly dilated left ventricle with a left ventricular ejection fraction of 45% and an apical thrombus. Extended semicircumferential subendocardial late enhancement with partial involvement of the papillary muscles was compatible with EMF.\n\nEnalapril and anticoagulation with enoxaparin followed by phenprocoumon were started for heart failure and the apical thrombus, respectively, and the patient was discharged in stable condition. For a second opinion and the development of a management plan, the patient was referred to a university heart failure unit with a focus on rare cardiomyopathies in November 2011. Endomyocardial biopsy was planned from the right ventricle - to avoid left ventricular thrombus mobilization – but was hampered by the dense consistency of the fibrotic endocardium. After several attempts the right ventricular free wall was perforated resulting in pericardial tamponade, which was immediately treated successfully by pericardiocentesis and drainage. In synopsis of all findings, the patient was given the diagnosis of EMF without another attempt for histological confirmation.\n\nFurther workup revealed no evidence of infection, systemic immunologic, hematological, or solid malignant disease. Microscopy on helminthic eggs or intestinal protozoa was negative. The patient progressively deteriorated with decreasing walking distances of < 100 m, semiorthopnoea, and increasing signs of congestion so that a rapid therapeutic decision was necessary. The interdisciplinary heart team, consisting of cardiologists and cardiac surgeons, discussed several therapeutic options and decided to evaluate and list the patient for heart transplantation.\n\nWhile on the waiting list, the patient’s condition initially stabilized with enalapril, bisoprolol, and furosemide. Due to continuous progression of heart failure starting in June 2012 she underwent high urgency heart transplantation in August 2012. Macroscopic and microscopic findings of the explanted heart confirmed the diagnosis of EMF. Both ventricles revealed severe fibrosis of the endocardium with apical predominance. The neighboring myocardium was characterized by hypervascularization, fibroblasts, chronic inflammatory infiltration with few mast cells and eosinophils as well as interstitial fibrosis in subendocardial layers. Six years after heart transplantation the patient was in an excellent clinical condition.\n\nMacroscopic image of explanted heart. Image shows severe fibrosis of the endocardium involving both ventricles.\n\n\nTimeline of patient’s history from first presentation until end of follow-up\n\nYear\tMonth\tHistory\n2010\tAugust\t• Holiday in Hurghada, Egypt\n2011\tJanuary\t\n• First presentation at emergency department with fever and exertional retrosternal chest pain\n\n• Discharge after 3 days without complaints\n\n• Suspected (Peri-)myocarditis\n\nSeptember\t\n• Re-hospitalization with chest pain for 1 week, dyspnea on minimal exertion (NYHA IV)\n\n• Comprehensive diagnostic work-up\n\n• Medical treatment for heart failure and anticoagulation for apical thrombus were started\n\n• Discharge in stable condition\n\n• Suspected EMF\n\nNovember\t\n• Referred to a university heart failure unit with a focus on rare cardiomyopathies for second opinion\n\n• Unsuccessful endomyocardial biopsy\n\n• Diagnosis of EMF without another attempt for histological confirmation\n\n2012\tJune\t• Continuous progression of heart failure\nAugust\t• High urgency heart transplantation\n2018\t\t• Excellent outcome after heart transplantation", + "fulltext_subclaims": [ + "The patient was a 40-year-old woman.", + "She was presented at the emergency department in January 2011.", + "She had a six-day history of fever up to 38.1 degrees Celsius every evening.", + "She had exertional retrosternal chest pain.", + "She reported no dyspnea.", + "She reported no abdominal pain.", + "She reported no urinary abnormalities.", + "She reported no stool abnormalities.", + "Her past medical history included an appendectomy at age 12.", + "Her past medical history included a caesarean section in 1993.", + "Her past medical history included a thyroidectomy in November 2010 due to Graves’ disease.", + "She had been on holiday in Hurghada, Egypt, approximately 5 months prior to presentation.", + "Her long-term medication included levothyroxin.", + "Her long-term medication included esomeprazole.", + "Her long-term medication included tizanidin.", + "Her primary care physician had prescribed amoxicillin/clavulanic acid the day before presentation.", + "She worked as a nurse in a nursing home for the elderly.", + "She smoked 15 cigarettes per day.", + "She had an allergy to house dust mites.", + "Her cardiovascular risk factors included smoking.", + "Her cardiovascular risk factors included hypercholesterolemia.", + "Her cardiovascular risk factors included a family history of myocardial infarction.", + "On arrival, her temperature was 36.9° Celsius.", + "On arrival, her blood pressure was 150 over 90 mmHg.", + "On arrival, her heart rate was 130 beats per minute.", + "On arrival, her oxygen saturation was 97% with ambient air.", + "The ECG revealed sinus tachycardia with a heart rate of 120 beats per minute.", + "The ECG showed slight T-wave inversion in leads V3-V6.", + "The white blood cell count was 13.2 G/l.", + "The C-reactive protein was 6.11 mg/dl.", + "The high sensitive Troponin-T was 67 pg/ml.", + "The D-Dimer was 2.06 mg/l.", + "The chest x-ray was unremarkable.", + "Computed tomography angiography showed no signs of pulmonary embolism.", + "The transthoracic echocardiogram revealed normal right and left ventricular function.", + "The echocardiogram showed no wall motion abnormalities.", + "The echocardiogram showed no evidence of valve disease.", + "The echocardiogram showed no pericardial effusion.", + "(Peri-)myocarditis was suspected.", + "The patient was admitted for observation.", + "The patient was discharged on day three.", + "Blood culture was negative.", + "Immunology tests were negative, except for perinuclear anti-neutrophil cytoplasmic antibodies which were elevated to 47 U/ml.", + "In September 2011, the patient was re-hospitalized with chest pain for 1 week.", + "In September 2011, the patient had dyspnea on minimal exertion (NYHA functional class IV).", + "The ECG detected a new P-mitrale.", + "The echocardiogram showed severe mitral regurgitation.", + "The echocardiogram showed dilated left and right atria.", + "The echocardiogram showed a restrictive filling pattern.", + "The echocardiogram showed elevated systolic pulmonary artery pressure.", + "Coronary angiography was unremarkable.", + "Invasive hemodynamic evaluation showed postcapillary pulmonary hypertension.", + "CMR imaging confirmed severe mitral regurgitation.", + "CMR imaging revealed a mildly dilated left ventricle with a left ventricular ejection fraction of 45%.", + "CMR imaging showed an apical thrombus.", + "CMR imaging showed extended semicircumferential subendocardial late enhancement.", + "The patient was diagnosed with EMF.", + "The patient was referred to a university heart failure unit in November 2011.", + "Endomyocardial biopsy was planned from the right ventricle.", + "Endomyocardial biopsy was hampered by the dense consistency of the fibrotic endocardium.", + "The right ventricular free wall was perforated during biopsy.", + "Pericardial tamponade was treated successfully by pericardiocentesis and drainage.", + "The diagnosis of EMF was given without another attempt for histological confirmation.", + "The patient was listed for heart transplantation.", + "The patient underwent high urgency heart transplantation in August 2012.", + "Macroscopic and microscopic findings of the explanted heart confirmed the diagnosis of EMF.", + "Both ventricles revealed severe fibrosis of the endocardium with apical predominance.", + "The neighboring myocardium showed hypervascularization.", + "The neighboring myocardium showed fibroblasts.", + "The neighboring myocardium showed chronic inflammatory infiltration.", + "The neighboring myocardium showed interstitial fibrosis in subendocardial layers.", + "Six years after heart transplantation, the patient was in an excellent clinical condition." + ], + "summary": "A 40-year-old woman was presented at our emergency department with chest pain and fever up to 38.1° Celsius. Plasma troponin-T levels and inflammatory markers were slightly elevated, but the echocardiogram was without pathological findings. The patient was hospitalized on the suspicion of acute myocarditis and discharged soon after improvement. Eight months later, she was presented again with chest pain and symptoms of heart failure. The echocardiogram showed normal systolic left ventricular (LV) function with LV wall thickening and severe restrictive mitral regurgitation as well as aortic and tricuspid regurgitation. Coronary angiogram was normal but right heart catheterization showed pulmonary hypertension due to left heart disease. Further diagnostic workup with cardiac magnetic resonance imaging revealed subendocardial late enhancement and apical thrombus formation in the left ventricle compatible with the diagnosis of EMF. A comprehensive diagnostic workup showed no evidence of infection, systemic immunologic or hematological disease, in particular hypereosinophilic syndrome. After a multidisciplinary consideration of several therapeutic options, the patient was listed for heart transplantation. On the waiting list, she deteriorated rapidly due to progressive heart failure and finally underwent a heart transplantation. Histological examination confirmed the diagnosis of EMF. Six years after her heart transplantation, the patient was presented in an excellent clinical condition.", + "summary_subclaims": [ + "A 40-year-old woman was presented at our emergency department with chest pain and fever up to 38.1° Celsius.", + "Plasma troponin-T levels and inflammatory markers were slightly elevated.", + "The echocardiogram was without pathological findings.", + "The patient was hospitalized on the suspicion of acute myocarditis.", + "The patient was discharged soon after improvement.", + "Eight months later, she was presented again with chest pain and symptoms of heart failure.", + "The echocardiogram showed normal systolic left ventricular (LV) function.", + "The echocardiogram showed LV wall thickening.", + "The echocardiogram showed severe restrictive mitral regurgitation.", + "The echocardiogram showed aortic and tricuspid regurgitation.", + "Coronary angiogram was normal.", + "Right heart catheterization showed pulmonary hypertension due to left heart disease.", + "Cardiac magnetic resonance imaging revealed subendocardial late enhancement.", + "Cardiac magnetic resonance imaging revealed apical thrombus formation in the left ventricle.", + "The findings were compatible with the diagnosis of EMF.", + "A comprehensive diagnostic workup showed no evidence of infection.", + "A comprehensive diagnostic workup showed no evidence of systemic immunologic or hematological disease.", + "A comprehensive diagnostic workup showed no evidence of hypereosinophilic syndrome.", + "The patient was listed for heart transplantation.", + "On the waiting list, she deteriorated rapidly due to progressive heart failure.", + "The patient finally underwent a heart transplantation.", + "Histological examination confirmed the diagnosis of EMF.", + "Six years after her heart transplantation, the patient was presented in an excellent clinical condition." + ] + }, + { + "id": "multiclinsum_test_379_en.txt", + "fulltext": "A 60-year-old Japanese man with a history of low anterior resection for rectal cancer 4 years ago was referred to our department because of a lung nodule detected on chest radiography during a routine medical checkup. He had no symptoms and presented with a body temperature of 35.9°C, blood pressure of 106/65 mmHg, heart rate of 59 beats per minute, and oxygen saturation of 99% on room air. His laboratory examination results were within normal limits. As his chest computed tomography (CT) revealed a 12-mm tumor in the left posterior basal bronchus during postoperative follow-up, he underwent six cycles of chemotherapy with mFOLFOX6 and bevacizumab at standard doses. After chemotherapy, he underwent chest and abdomen CT scans, which confirmed that the tumor deeply seated in the segment had been growing continuously up to 15 mm . Fluorodeoxyglucose positron emission tomography (FDG-PET) revealed an abnormal uptake of FDG, with a maximum standardized uptake value of 2.28 in the tumor. Hence, the patient was treated with a portal robotic S9–10 segmentectomy through a PL approach.\nOn the basis of the patient’s actual three-dimensional (3-D) pulmonary model, created using an in-house software as presented in the preoperative CT images, the involvement of the pulmonary vessels and bronchi were identified and the location and extent of tumor invasion were assessed to determine the surgical procedure [–].\nUnder general anesthesia with single-lung ventilation and lateral decubitus positioning, RATS S9–10 segmentectomy was performed with five-port incisions, including an assistant port as a carbon dioxide (CO2) insufflation port. With the pleural space as the entry point, a 12-mm trocar (AirSeal access ports, ConMed, Utica, NY, USA) was inserted as an assistant port in the fifth intercostal space (ICS) anteriorly in the anterior axillary line. Moreover, two 8-mm robotic trocars were inserted, one as a port for the robotic camera in the ninth ICS at the middle axillary line and the other as port 4 on the posterior side of the tip of the scapula. Two 12-mm robotic trocars were inserted in port 1 and 3 in the eighth ICS anteriorly along the anterior axillary line and in the ninth ICS along the posterior axillary line, respectively, after which the da Vinci Xi surgical system (Intuitive Surgery, Sunnyvale, CA, USA) was docked . All four robotic arms were used. A CO2 insufflation system (AirSeal system, ConMed) was used at a set pressure of 5 mmHg. The robotic instruments were manipulated through a 12-mm port mounting a 12–8-mm reducer. Fenestrated bipolar forceps, a permanent cautery spatula, and Cadiere forceps were inserted through ports 1, 3, and 4 (Intuitive Surgical), respectively. After lifting the left lower lobe using the Cadiere forceps, the PL was incised up to the inferior pulmonary vein. The basal pulmonary vein was exposed, and both the lateral (V9) and posterior basal veins (V10) were transected using robot staplers . Next, the intersegmental septum was dissected to expose the bronchi and pulmonary arteries. First, the targeted bronchi were exposed and transected, followed by the targeted pulmonary arteries . An intravenous injection of indocyanine green was administered, and observation under fluorescence navigation revealed intersegmental planes, which were marked using the fenestrated bipolar forceps and permanent cautery spatula, after which the target S9–10 segments were resected using the robot staplers . An additional movie file shows this procedure in detail (Additional file ).\nThe final histopathological investigations confirmed the resected tumor to be a lung metastasis of rectal cancer. The postoperative course was uneventful. Postoperatively, he received no adjuvant chemotherapy. No recurrence was observed for 6 months after the operation.", + "fulltext_subclaims": [ + "The patient is a 60-year-old Japanese man.", + "He had a history of low anterior resection for rectal cancer 4 years ago.", + "A lung nodule was detected on chest radiography during a routine medical checkup.", + "He had no symptoms.", + "His body temperature was 35.9°C.", + "His blood pressure was 106/65 mmHg.", + "His oxygen saturation was 99% on room air.", + "His laboratory examination results were within normal limits.", + "Chest computed tomography revealed a 12-mm tumor in the left posterior basal bronchus.", + "He underwent six cycles of chemotherapy with mFOLFOX6 and bevacizumab at standard doses.", + "After chemotherapy, chest and abdomen CT scans confirmed the tumor had grown continuously up to 15 mm.", + "FDG-PET revealed an abnormal uptake of FDG with a maximum standardized uptake value of 2.28 in the tumor.", + "The patient was treated with a portal robotic S9–10 segmentectomy through a PL approach.", + "A 3-D pulmonary model was created using in-house software based on preoperative CT images.", + "The involvement of pulmonary vessels and bronchi was identified.", + "The location and extent of tumor invasion were assessed.", + "RATS S9–10 segmentectomy was performed with five-port incisions.", + "A 12-mm trocar was inserted as an assistant port in the fifth ICS anteriorly in the anterior axillary line.", + "Two 8-mm robotic trocars were inserted, one for the robotic camera in the ninth ICS at the middle axillary line and one as port 4 on the posterior side of the tip of the scapula.", + "Two 12-mm robotic trocars were inserted in port 1 and 3.", + "The da Vinci Xi surgical system was used.", + "A CO2 insufflation system was used at a set pressure of 5 mmHg.", + "The robotic instruments were manipulated through a 12-mm port mounting a 12–8-mm reducer.", + "Fenestrated bipolar forceps, a permanent cautery spatula, and Cadiere forceps were inserted through ports 1, 3, and 4, respectively.", + "The PL was incised up to the inferior pulmonary vein.", + "The basal pulmonary vein was exposed.", + "Both the lateral (V9) and posterior basal veins (V10) were transected using robot staplers.", + "The intersegmental septum was dissected to expose the bronchi and pulmonary arteries.", + "The targeted bronchi were exposed and transected.", + "The targeted pulmonary arteries were transected.", + "An intravenous injection of indocyanine green was administered.", + "Observation under fluorescence navigation revealed intersegmental planes.", + "The intersegmental planes were marked using the fenestrated bipolar forceps and permanent cautery spatula.", + "The target S9–10 segments were resected using the robot staplers.", + "The final histopathological investigations confirmed the resected tumor to be a lung metastasis of rectal cancer.", + "The postoperative course was uneventful.", + "He received no adjuvant chemotherapy.", + "No recurrence was observed for 6 months after the operation." + ], + "summary": "A 60-year-old Japanese man with a history of low anterior resection for rectal cancer was referred to our department because of a lung nodule. His chest computed tomography revealed a 15-mm tumor in the left posterior basal bronchus. Robotic left S9-10 segmentectomy through the pulmonary ligament was performed with five-port incisions.", + "summary_subclaims": [ + "The patient is a 60-year-old Japanese man.", + "He had a history of low anterior resection for rectal cancer.", + "He was referred to the department because of a lung nodule.", + "Chest computed tomography revealed a 15-mm tumor in the left posterior basal bronchus.", + "Robotic left S9-10 segmentectomy through the pulmonary ligament was performed.", + "The surgery was performed with five-port incisions." + ] + }, + { + "id": "multiclinsum_test_635_en.txt", + "fulltext": "A 43-year-old male with a history of a C2 fracture sustained 28 years ago, now presented with the 10-day duration of the onset of a severe spastic quadriparesis with sphincter dysfunction. His motor examination was 2/5 in all distributions, accompanied by hyperreflexia and a C2 sensory level.\nThe CT scan of the cervical spine demonstrated a chronic pseudarthrosis of a C2 Type II odontoid fracture. This was accompanied by anterior subluxation and a significant ventral osteophyte, all of which narrowed the spinal canal. The C2 odontoid fracture warranted a two-stage circumferential procedure. The first part included an anterior transoral decompression of the odontoid fragment (e.g., with resection of the ventral osteophyte to achieve anterior spinal cord decompression). The second part performed posteriorly warranted a C1 laminectomy, subaxial decompression, and C1-C2 fusion. Following this extensive circumferential approach, the postoperative course was unremarkable, and the patient was discharged with Philadelphia collar.", + "fulltext_subclaims": [ + "The patient is a 43-year-old male.", + "The patient has a history of a C2 fracture sustained 28 years ago.", + "The patient presented with a 10-day duration of the onset of severe spastic quadriparesis.", + "The patient had sphincter dysfunction.", + "The motor examination was 2/5 in all distributions.", + "The patient had hyperreflexia.", + "The patient had a C2 sensory level.", + "The CT scan of the cervical spine demonstrated a chronic pseudarthrosis of a C2 Type II odontoid fracture.", + "The CT scan showed anterior subluxation.", + "The CT scan showed a significant ventral osteophyte.", + "The CT scan showed narrowing of the spinal canal.", + "The C2 odontoid fracture warranted a two-stage circumferential procedure.", + "The first part of the procedure included an anterior transoral decompression of the odontoid fragment.", + "The first part included resection of the ventral osteophyte to achieve anterior spinal cord decompression.", + "The second part of the procedure was performed posteriorly.", + "The second part included a C1 laminectomy.", + "The second part included subaxial decompression.", + "The second part included C1-C2 fusion.", + "Following the extensive circumferential approach, the postoperative course was unremarkable.", + "The patient was discharged with a Philadelphia collar." + ], + "summary": "Here, we present a 43-year-old male who sustained cervical trauma 28 years ago. He now presented with an acute 10-day onset of quadriparesis attributed to a chronic malunion of an unstable type II odontoid fracture. He successfully underwent a circumferential decompression and fusion (e.g., warranting a trans-oral odontoidectomy followed by C1-C3 posterior fusion).", + "summary_subclaims": [ + "The patient is a 43-year-old male.", + "He sustained cervical trauma 28 years ago.", + "He now presented with an acute 10-day onset of quadriparesis.", + "The quadriparesis was attributed to a chronic malunion of an unstable type II odontoid fracture.", + "He successfully underwent a circumferential decompression and fusion.", + "The procedure included a trans-oral odontoidectomy.", + "The procedure included a C1-C3 posterior fusion." + ] + }, + { + "id": "multiclinsum_test_1439_en.txt", + "fulltext": "A 53-year-old, right-handed male patient presented with sudden onset of right hemiparesis and aphasia. Left middle cerebral artery (MCA) stroke was diagnosed. The patient's medical history included systemic hypertension and dyslipidemia. Previously undiagnosed atrial fibrillation was then identified. Systemic fibrinolytic therapy was administered first without result; local intraarterial fibrinolytic treatment and mechanical thrombectomy were then performed, achieving recanalization of the distal MCA.\nComputed tomography angiography (CTA) that was performed during the diagnosis of the stroke also revealed an aneurysm of the PCoA . No signs of subarachnoid hemorrhage were observed in the basal cisterns, and the patient had no focal cranial nerve deficits prior to the stroke. The aneurysm measured 3 mm and had a posterior orientation. A day after the stroke, magnetic resonance imaging (MRI) showed a mass in the interpeduncular fossa that was larger than expected . The mass measured 14 mm, projected medially, and was compatible with a partially thrombosed aneurysm.\nBilateral carotid and left vertebral angiography [Figures and ] revealed an aneurysm arising from the left PCoA itself. The saccular-type aneurysm originated 3 mm distal to the ICA bifurcation, with a 3.5 mm dome height and a 1.5 mm neck width. A fetal-type posterior cerebral artery (PCA) was present on the left. We opted for endovascular treatment of the aneurysm because the configuration of the aneurysm was favorable in our opinion, rather than surgical clipping. Endovascular occlusion was performed under general anesthesia in a separate procedure. A guide catheter was introduced to the right ICA. Then a microcatheter was placed into the aneurysm sac in the PCoA. Once the microcatheter was placed three coils were packed (3 × 80, 2 × 60, and 2 × 40 mm) until no additional coil could fit into the lumen. Postcoiling angiogram showed complete occlusion of the aneurysm . The postprocedure course was uneventful.\nAt the 6-month follow-up, magnetic resonance angiography (MRA) did not show recanalization. The patient exhibited marked neurological improvement with therapy, presenting with mild right hemiparesis and motor dysphasia with mild nonfluent speech and normal comprehension.", + "fulltext_subclaims": [ + "The patient was a 53-year-old, right-handed male.", + "The patient presented with sudden onset of right hemiparesis and aphasia.", + "Left middle cerebral artery (MCA) stroke was diagnosed.", + "The patient's medical history included systemic hypertension.", + "The patient's medical history included dyslipidemia.", + "Previously undiagnosed atrial fibrillation was identified.", + "Systemic fibrinolytic therapy was administered first.", + "Systemic fibrinolytic therapy did not result in improvement.", + "Local intraarterial fibrinolytic treatment was performed.", + "Mechanical thrombectomy was performed.", + "Recanalization of the distal MCA was achieved.", + "Computed tomography angiography (CTA) revealed an aneurysm of the PCoA.", + "No signs of subarachnoid hemorrhage were observed in the basal cisterns.", + "The aneurysm measured 3 mm.", + "The aneurysm had a posterior orientation.", + "Magnetic resonance imaging (MRI) showed a mass in the interpeduncular fossa.", + "The mass was larger than expected.", + "The mass measured 14 mm.", + "The mass projected medially.", + "The mass was compatible with a partially thrombosed aneurysm.", + "Bilateral carotid and left vertebral angiography revealed an aneurysm arising from the left PCoA itself.", + "The saccular-type aneurysm originated 3 mm distal to the ICA bifurcation.", + "The aneurysm had a 3.5 mm dome height.", + "The aneurysm had a 1.5 mm neck width.", + "A fetal-type posterior cerebral artery (PCA) was present on the left.", + "Endovascular treatment of the aneurysm was performed.", + "Endovascular treatment was chosen because the configuration of the aneurysm was favorable in our opinion.", + "Endovascular occlusion was performed under general anesthesia.", + "A guide catheter was introduced to the right ICA.", + "A microcatheter was placed into the aneurysm sac in the PCoA.", + "Three coils were packed into the aneurysm sac.", + "Postcoiling angiogram showed complete occlusion of the aneurysm.", + "The postprocedure course was uneventful.", + "At the 6-month follow-up, magnetic resonance angiography (MRA) did not show recanalization.", + "The patient exhibited marked neurological improvement with therapy.", + "The patient presented with mild right hemiparesis.", + "The patient had motor dysphasia with mild nonfluent speech.", + "The patient had normal comprehension." + ], + "summary": "A 53-year-old male presented with sudden onset of right hemiparesis and aphasia. Left middle cerebral artery stroke was diagnosed. Further studies revealed a 3 mm left PCoA aneurysm arising from the PCoA itself, attached to neither the internal carotid artery nor the posterior cerebral artery. Endovascular treatment was performed and the aneurysm was coiled completely.", + "summary_subclaims": [ + "The patient is a 53-year-old male.", + "The patient presented with sudden onset of right hemiparesis.", + "The patient presented with aphasia.", + "Left middle cerebral artery stroke was diagnosed.", + "A 3 mm left PCoA aneurysm was found.", + "The aneurysm arose from the PCoA itself.", + "The aneurysm was attached to neither the internal carotid artery nor the posterior cerebral artery.", + "Endovascular treatment was performed.", + "The aneurysm was coiled completely." + ] + }, + { + "id": "multiclinsum_test_228_en.txt", + "fulltext": "A 41-year-old woman with CF was admitted for a course of intravenous antibiotics after developing worsening respiratory symptoms of increased cough, sputum volume and purulence and worsening breathlessness on exercise. She had lost 3 kg in weight and felt generally unwell. Her FEV1 had fallen from 860 mL to 780 mL. During the course of her admission, she volunteered that she had noted intermittent rectal bleeding and that the blood appeared to be mixed in with her stools.\nThe patient's CF genotype was DF508/N1303K. She had severe lung disease and was chronically infected with mucoid Pseudomonas aeruginosa. She was pancreatic insufficient and had CF-related diabetes (CFRD), as well as mild CF-related biliary cirrhosis. Treatment when stable consisted of rotating oral and nebulised antibiotics, nebulised DNAse and hypertonic saline, pancreatic enzyme replacement, fat-soluble vitamin supplements and insulin.\nThe question of lung transplantation had been raised previously and the patient had undergone formal assessment for this in 2005, but following discussions with the transplant team had decided to delay listing because lung function, albeit very poor, had remained stable over the preceding 5 years and her quality-of-life was still reasonable.\nExamination revealed a woman at the lower limit of the healthy weight range (BMI 20.2). She was clubbed but there were no signs of anaemia or stigmata of chronic liver disease. Scattered inspiratory crepitations were present throughout both lung fields, especially over the upper lobes, but these findings were unchanged from previous recordings. On abdominal examination, there was no tenderness or palpable masses. Rectal examination was normal. Initial investigations revealed a normal haemoglobin, renal function and serum amylase. Liver enzymes were normal except for a slightly raised serum alkaline phosphatase at 155 IU/L (normal range 45 to 115 IU/L). Chest radiograph showed over-inflated lungs with fibrotic scarring and ring shadows, particularly in the upper lobes, consistent with her advanced lung disease. Full lung function testing showed an FEV1 of 0.78 L (29% predicted), forced vital capacity (FVC) of 1.29 L (41% predicted), and evidence of gas trapping with a residual volume of 210% predicted as well as a reduced carbon monoxide transfer factor (TLCO) of 12.86 mL/min/mmHg (52% predicted) that normalised when corrected for alveolar volume.\nAt colonoscopy, a large pedunculated polyp was seen in the distal sigmoid colon and the top of this was removed. Histopathology demonstrated a moderately differentiated adenocarcinoma arising on a background of a severely dysplastic tubulovillous adenoma. Invasive tumour was apparent at the surgical resection margin. There was no immunohistochemical evidence of mutation in the mismatch repair genes MLH1, MSH2 and MSH6.\nA staging computed tomography (CT) scan with contrast of the chest, abdomen and pelvis did not demonstrate the primary malignancy or any metastases within the abdomen.\nAfter a second unsuccessful attempt at endoscopic resection, the patient elected to undergo potentially curative laparoscopic resection. She was transferred to a large tertiary referral hospital in another state that has a fully staffed multidisciplinary CF Unit providing care to over 220 patients. Tasmanians do not have access to this sort of dedicated care team and it was thought that the patient's chances of survival postoperatively would be increased if 24-hour access to a multidisciplinary CF team was available.\nAs part of the pre-operative staging, a positron emission tomography (PET) scan was undertaken and this demonstrated increased uptake in enlarged mediastinal lymph nodes which were thought reactive and consistent with her chronic pulmonary sepsis. There was no uptake in the abdomen to suggest loco-regional metastatic disease. A laparoscopic anterior resection was performed under general anaesthetic. The procedure was tolerated remarkably well. Operative time was 4 hours during which she maintained oxygen saturations between 97% and 100% on a FiO2 of 38%. She was extubated successfully and had an uncomplicated postoperative course. She rapidly weaned herself off a fentanyl infusion (Patient Controlled Analgesia) within 24 hours and was able to undertake chest physiotherapy and airway clearance techniques under the supervision of a CF physiotherapist on the first evening post-operation. Before the operation, she had received continuous intravenous antibiotics for 41 days and these were continued for a further 6 days postoperatively until she was discharged. Histopathology of the resected segment of colon revealed a Stage I (T1N0) moderately differentiated adenocarcinoma with clear resection margins. Adjuvant therapy was not considered appropriate. She has remained very well over the 12 months since her return to Tasmania and a restaging CT scan of the abdomen and colonoscopy have shown no evidence of recurrence.", + "fulltext_subclaims": [ + "The patient is a 41-year-old woman with cystic fibrosis.", + "She was admitted for intravenous antibiotics after developing worsening respiratory symptoms.", + "Her symptoms included increased cough, sputum volume and purulence, and worsening breathlessness on exercise.", + "She had lost 3 kg in weight.", + "Her FEV1 had fallen from 860 mL to 780 mL.", + "She noted intermittent rectal bleeding mixed in with her stools.", + "Her CF genotype was DF508/N1303K.", + "She was chronically infected with mucoid Pseudomonas aeruginosa.", + "She had CF-related diabetes.", + "She had mild CF-related biliary cirrhosis.", + "She had undergone formal assessment for lung transplantation in 2005.", + "She decided to delay listing for lung transplantation.", + "Her BMI was 20.2.", + "She was clubbed.", + "Scattered inspiratory crepitations were present throughout both lung fields.", + "Chest radiograph showed over-inflated lungs with fibrotic scarring and ring shadows.", + "Full lung function testing showed an FEV1 of 0.78 L (29% predicted).", + "Colonoscopy revealed a large pedunculated polyp in the distal sigmoid colon.", + "Histopathology demonstrated a moderately differentiated adenocarcinoma arising on a background of a severely dysplastic tubulovillous adenoma.", + "Invasive tumour was apparent at the surgical resection margin.", + "A staging CT scan did not demonstrate the primary malignancy or any metastases within the abdomen.", + "After a second unsuccessful attempt at endoscopic resection, the patient elected to undergo potentially curative laparoscopic resection.", + "She was transferred to a large tertiary referral hospital in another state.", + "A PET scan demonstrated increased uptake in enlarged mediastinal lymph nodes.", + "A laparoscopic anterior resection was performed under general anaesthetic.", + "The procedure was tolerated remarkably well.", + "Operative time was 4 hours.", + "She was extubated successfully.", + "She had an uncomplicated postoperative course.", + "She rapidly weaned herself off a fentanyl infusion within 24 hours.", + "She was able to undertake chest physiotherapy and airway clearance techniques on the first evening post-operation.", + "Before the operation, she had received continuous intravenous antibiotics for 41 days.", + "Antibiotics were continued for a further 6 days postoperatively until she was discharged.", + "Histopathology of the resected segment of colon revealed a Stage I (T1N0) moderately differentiated adenocarcinoma with clear resection margins.", + "Adjuvant therapy was not considered appropriate.", + "She has remained very well over the 12 months since her return to Tasmania.", + "A restaging CT scan of the abdomen and colonoscopy have shown no evidence of recurrence." + ], + "summary": "We describe a 41-year-old Caucasian woman with cystic fibrosis and severe lung disease who had been considered for lung transplantation, who presented with rectal bleeding and was found to have a Stage I adenocarcinoma of the sigmoid colon. After considerable discussion as to the operative risks, she underwent a laparoscopic resection and remains relatively well 1 year postoperatively with no recurrence.", + "summary_subclaims": [ + "The patient is a 41-year-old Caucasian woman.", + "She has cystic fibrosis.", + "She has severe lung disease.", + "She had been considered for lung transplantation.", + "She presented with rectal bleeding.", + "She was found to have a Stage I adenocarcinoma of the sigmoid colon.", + "After considerable discussion as to the operative risks, she underwent a laparoscopic resection.", + "She remains relatively well 1 year postoperatively.", + "There is no recurrence." + ] + }, + { + "id": "multiclinsum_test_1231_en.txt", + "fulltext": "A 39-year-old male patient with MEN-1 who had an anterior mediastinal mass was referred to our hospital. The patient had undergone total parathyroidectomy and auto-transplantation of a partial parathyroid for hyperparathyroidism 6 years ago. His vital signs showed no abnormalities. He had a temperature of 37.2 °C, blood pressure of 117/72 mmHg, heart rate of 100 bpm, respiratory rate of 16 breaths per minute, and oxygen saturation of 98% in room air. Laboratory data revealed a serum antiacetylcholine receptor binding antibody level below 0.2 nmol/L (normal, below 0.2 nmol/L), serum cancer antigen level 5 U/mL (normal, below 35 U/mL), serum α-fetoprotein level 3 ng/mL (normal, below 10 ng/mL), serum human chorionic gonadotropin β subunit level below 0.5 mIU/mL (normal, below 0.5 mIU/mL), and serum soluble interleukin-2 receptor level 292 U/mL (normal, below 475 U/mL).\nChest computed tomography revealed an isolated anterior mediastinal mass on the thymic gland with a maximum diameter measuring 22 mm and without invasion into the surrounding tissues . Thymic carcinoid is classified as MEN-1 and has a poor prognosis; thus, we decided to remove the tumor. The patient was intubated with a double-lumen endotracheal tube for one-lung ventilation under general anesthesia and positioned in the left lateral decubitus position. A 5-cm skin incision was made at the fifth intercostal space (ICS) in the anterior axillary line, and a wound protector (Gel POINT Mini Advanced Access Platform, Applied Medical, Rancho Santa Margarita, CA, USA) was placed at the subcutaneous muscular layer . Through the wound protector, an 8-mm camera port was placed at the fifth ICS in the anterior axillary line as the second arm. Two 8-mm assisted ports were inserted at the fourth and sixth ICS on the anterior side as the first and third arms, respectively . The distance between each port was about 3 cm. After the da Vinci® Xi (Intuitive Surgical, Sunnyvale, CA, USA) was positioned; a robotic arm was mounted to each port with a bipolar fenestrated grasping forceps on the first arm and a monopolar spatula on the third arm. The rigid 30° oblique viewing endoscope was used. Carbon dioxide (CO2) was insufflated at a set pressure of 5 mmHg. Depending on the situation, the robotic instruments on the left and right arms were replaced and da Vinci® Vessel Sealer Extend (Intuitive Surgical) instruments were also used. Part of the thymic and pericardial fat including the tumor was dissected from the inferior side, and complete dissection was performed from the cranial side, resulting in the removal of the tumor. To prevent robotic arm collisions, the left and right forceps were moved vertically with the endoscope in between . The final histopathologic examination diagnosed the tumor as a thymic carcinoid tumor . Hematoxylin and eosin staining revealed the presence of a number of atypical pleomorphic cells. Immunohistochemical staining showed the presence of neuroendocrine markers chromogranin A, synaptophysin, cytokeratin AE1/3, and Ki-67 (5–10%) . Thus, confirmation of a thymic carcinoid tumor was obtained. The postoperative course was uneventful.", + "fulltext_subclaims": [ + "The patient is a 39-year-old male.", + "The patient has MEN-1.", + "The patient had an anterior mediastinal mass.", + "The patient had undergone total parathyroidectomy and auto-transplantation of a partial parathyroid for hyperparathyroidism 6 years ago.", + "The patient's temperature was 37.2 °C.", + "The patient's blood pressure was 117/72 mmHg.", + "The patient's heart rate was 100 bpm.", + "The patient's oxygen saturation was 98% in room air.", + "The serum antiacetylcholine receptor binding antibody level was below 0.2 nmol/L.", + "The serum cancer antigen level was 5 U/mL.", + "The serum α-fetoprotein level was 3 ng/mL.", + "The serum human chorionic gonadotropin β subunit level was below 0.5 mIU/mL.", + "The serum soluble interleukin-2 receptor level was 292 U/mL.", + "Chest computed tomography revealed an isolated anterior mediastinal mass on the thymic gland with a maximum diameter measuring 22 mm.", + "The mass did not show invasion into the surrounding tissues.", + "Thymic carcinoid is classified as MEN-1.", + "Thymic carcinoid has a poor prognosis.", + "The tumor was removed.", + "The patient was intubated with a double-lumen endotracheal tube for one-lung ventilation under general anesthesia.", + "A 5-cm skin incision was made at the fifth intercostal space in the anterior axillary line.", + "A wound protector was placed at the subcutaneous muscular layer.", + "An 8-mm camera port was placed at the fifth intercostal space in the anterior axillary line as the second arm.", + "Two 8-mm assisted ports were inserted at the fourth and sixth intercostal spaces on the anterior side as the first and third arms, respectively.", + "The distance between each port was about 3 cm.", + "The da Vinci® Xi was positioned and a robotic arm was mounted to each port.", + "A bipolar fenestrated grasping forceps was used on the first arm.", + "A monopolar spatula was used on the third arm.", + "The rigid 30° oblique viewing endoscope was used.", + "Carbon dioxide was insufflated at a set pressure of 5 mmHg.", + "The robotic instruments on the left and right arms were replaced depending on the situation.", + "The tumor was dissected from the inferior side.", + "Complete dissection was performed from the cranial side.", + "The tumor was removed.", + "The final histopathologic examination diagnosed the tumor as a thymic carcinoid tumor.", + "Hematoxylin and eosin staining revealed the presence of a number of atypical pleomorphic cells.", + "Immunohistochemical staining showed the presence of neuroendocrine markers chromogranin A, synaptophysin, cytokeratin AE1/3, and Ki-67 (5–10%).", + "The postoperative course was uneventful." + ], + "summary": "A 39-year-old male patient with multiple endocrine neoplasia type 1 (MEN-1) who had an anterior mediastinal mass was referred to our hospital. The patient had undergone total parathyroidectomy and auto-transplantation of a partial parathyroid for hyperparathyroidism 6 years ago. Chest computed tomography revealed an isolated anterior mediastinal mass on the thymic gland with a maximum diameter measuring 22 mm. Thymic carcinoid tumor is classified as MEN-1 and has a poor prognosis, so we decided to remove the tumor. Single-incision port RATS was performed, and thymic carcinoid was confirmed in pathology.", + "summary_subclaims": [ + "The patient is a 39-year-old male.", + "The patient has multiple endocrine neoplasia type 1.", + "The patient had an anterior mediastinal mass.", + "The patient had undergone total parathyroidectomy and auto-transplantation of a partial parathyroid for hyperparathyroidism 6 years ago.", + "Chest computed tomography revealed an isolated anterior mediastinal mass on the thymic gland.", + "The mass had a maximum diameter measuring 22 mm.", + "Thymic carcinoid tumor is classified as MEN-1.", + "Thymic carcinoid tumor has a poor prognosis.", + "Single-incision port RATS was performed.", + "Thymic carcinoid was confirmed in pathology." + ] + }, + { + "id": "multiclinsum_test_1649_en.txt", + "fulltext": "A 52-year-old man was first diagnosed with HIV in 1991. He was maintained on antiretroviral therapy with emtricitabine-tenofovir and raltegravir. The HIV viral load was undetectable (less than 20 copies/ml) and the CD4 count of 850 cells/uL at the time of presentation. In December 2016, he presented to the emergency department with chief complaint of diplopia. A magnetic resonance imaging (MRI) of the orbits revealed a mass in the left orbit with involvement of the optic nerve. He was referred to ophthalmology and underwent a lateral orbitotomy and removal of the orbital mass. Pathology showed metastatic small cell carcinoma. A Computed Tomography (CT) scan of the chest, abdomen and pelvis and a Positron Emission Tomography (PET) scans were negative for any intrathoracic mass; however, there were multiple liver lesions and a large pancreatic tail mass. Given these findings his final diagnosis was extrapulmonary high-grade small cell carcinoma of the pancreas. Next Generation Sequencing of his tumor showed an intermediate tumor mutation burden with 9 mutations/megabases and deleterious alterations in TP53, MLL3, MEN1, FAT1, CDKN2A, BCORL1, BCOR, ATRX and TSC2 genes. There is currently no approved targeted therapy for any of these mutations. He was started on chemotherapy with carboplatin and etoposide. He had a partial response (PR) after 2 cycles of chemotherapy. He had disease progression after 6 cycles of chemotherapy with carboplatin and etoposide. He was then started on chemotherapy with FOLFIRINOX (5-Fluorouracil, irinotecan, leucovorin and oxaliplatin) as second line therapy. He received four cycles but continued to have disease progression on imaging. He was then treated with carboplatin and paclitaxel but his disease continued to progress with clinical deterioration and significant abdominal pain. At that point, treatment with dual CPI therapy (nivolumab and ipilimumab) was pursued given the available data in refractory SCLC. Before the start of this therapy, his CD 4 count was 294 cells/uL with an undetectable HIV viral load (less than 20 copies/ml). He received Nivolumab 1 mg/Kg along with Ipilimumab 3 mg/kg every 3 weeks. After 2 doses of the combination, he developed acute kidney injury with creatinine of 4.2 mg/dl from a baseline of 1.0. The therapy was suspended and he was admitted to the hospital and a renal biopsy was performed which showed severe drug-induced acute interstitial nephritis (AIN). He was treated with high dose steroids; 500 mg of IV methylprednisolone for 3 days followed by a steroid taper. His renal function improved after 4 weeks with return of creatinine to baseline. He was then re-started on single agent Nivolumab at 1 mg/Kg and later ipilimumab at 1 mg/kg was added. The patient had significant clinical improvement soon after starting the dual CPI therapy with resolution of abdominal pain which previously required high-dose opioids. Repeat scans at 12 weeks (including MRI of the head and PET/CT scan) showed complete response (CR) as per PERCIST criteria with disappearance of all metabolically active lesions . Patient was continued on antiretroviral therapy. The HIV viral load was undetectable before starting the CPIs (< 20 copies/ml) and increased to a high of 175 copies/ml. At the same time his absolute CD4 count increased from 294 cells/uL before treatment to a high of 593 cells/uL. His CD8 count also followed the similar pattern. It was 111 cell/uL before starting treatment and reached a high of 247 cells/uL . The patient’s complete radiological response is still ongoing at the time of this report (24 weeks after the start of the dual CPI therapy).", + "fulltext_subclaims": [ + "The patient was first diagnosed with HIV in 1991.", + "He was maintained on antiretroviral therapy with emtricitabine-tenofovir and raltegravir.", + "The HIV viral load was undetectable (less than 20 copies/ml) at the time of presentation.", + "The CD4 count was 850 cells/uL at the time of presentation.", + "In December 2016, he presented to the emergency department with diplopia.", + "An MRI of the orbits revealed a mass in the left orbit with involvement of the optic nerve.", + "He underwent a lateral orbitotomy and removal of the orbital mass.", + "Pathology showed metastatic small cell carcinoma.", + "A CT scan of the chest, abdomen, and pelvis and a PET scan were negative for any intrathoracic mass.", + "There were multiple liver lesions and a large pancreatic tail mass.", + "His final diagnosis was extrapulmonary high-grade small cell carcinoma of the pancreas.", + "Next Generation Sequencing of his tumor showed an intermediate tumor mutation burden with 9 mutations/megabases.", + "There are no approved targeted therapies for the identified mutations.", + "He was started on chemotherapy with carboplatin and etoposide.", + "He had a partial response after 2 cycles of chemotherapy.", + "He had disease progression after 6 cycles of chemotherapy with carboplatin and etoposide.", + "He was then started on FOLFIRINOX as second line therapy.", + "He received four cycles of FOLFIRINOX.", + "He continued to have disease progression on imaging.", + "He was then treated with carboplatin and paclitaxel.", + "His disease continued to progress with clinical deterioration and significant abdominal pain.", + "Treatment with dual CPI therapy (nivolumab and ipilimumab) was pursued.", + "Before the start of CPI therapy, his CD4 count was 294 cells/uL.", + "The HIV viral load was undetectable before starting CPI therapy (less than 20 copies/ml).", + "He received Nivolumab 1 mg/Kg along with Ipilimumab 3 mg/kg every 3 weeks.", + "After 2 doses of the combination, he developed acute kidney injury with creatinine of 4.2 mg/dl.", + "The therapy was suspended.", + "A renal biopsy showed severe drug-induced acute interstitial nephritis.", + "He was treated with high dose steroids.", + "His renal function improved after 4 weeks with return of creatinine to baseline.", + "He was then re-started on single agent Nivolumab at 1 mg/Kg.", + "Ipilimumab at 1 mg/kg was later added.", + "The patient had significant clinical improvement soon after starting the dual CPI therapy.", + "Repeat scans at 12 weeks showed complete response as per PERCIST criteria.", + "The HIV viral load increased to a high of 175 copies/ml.", + "The absolute CD4 count increased from 294 cells/uL before treatment to a high of 593 cells/uL.", + "The CD8 count was 111 cell/uL before starting treatment.", + "The CD8 count reached a high of 247 cells/uL.", + "The patient’s complete radiological response is still ongoing at the time of this report." + ], + "summary": "We present a case of an HIV-positive patient with extensive extrapulmonary high-grade small cell carcinoma who was treated with dual CPIs (nivolumab and ipilimumab) with a complete response to therapy and with a manageable safety profile. We performed a comprehensive literature review identifying 62 total HIV positive cases treated with CPIs showing this to be a potentially safe option in HIV-positive patients.", + "summary_subclaims": [ + "The patient was HIV-positive.", + "The patient had extensive extrapulmonary high-grade small cell carcinoma.", + "The patient was treated with dual CPIs (nivolumab and ipilimumab).", + "The patient had a complete response to therapy.", + "The safety profile was manageable.", + "A comprehensive literature review identified 62 total HIV-positive cases treated with CPIs.", + "This case suggests CPIs may be a potentially safe option in HIV-positive patients." + ] + }, + { + "id": "multiclinsum_test_2330_en.txt", + "fulltext": "A 53-year-old male presented with a 4-day history of worsening chest pain. The pain was initially felt as episodic left sided non-radiating heaviness that resolved on rest, but in the last 24 h became constant and severe with associated sweating and shortness of breath. He had no known medical conditions but was a smoker.\nECG showed inferior ST elevation with Q waves. A coronary angiogram confirmed occlusion of the mid right coronary artery; aspiration thrombectomy and coronary stenting with drug-eluting stent were undertaken as complete occlusion likely occurred 24 h before a presentation and was performed successfully. He was admitted to the coronary intensive care unit, with still intermittent chest pain, but no murmurs on auscultation and improving ST elevation on sequential ECGs.\nHe remained persistently hypotensive post-procedure including an episode of cardiac tamponade with profound hypotension secondary to a haemorrhagic pericardial effusion that was emergently drained 10 h after coronary revascularization. Transthoracic echocardiogram (TTE) and cardiac computed tomography (CT) revealed a post-myocardial infarction inferior muscular VSD (14 × 16 mm and 12 × 17 mm diameter on TTE and CT, respectively, ). There was possibly an additional smaller VSD towards the base and an LV pseudoaneurysm due to inferior wall thinning or rupture that was felt to have been the cause of the haemorrhagic effusion.\nAfter extensive multidisciplinary discussion, percutaneous VSD closure under fluoroscopy and transoesophageal echocardiogram (TOE) guidance was undertaken in view of ongoing patient haemodynamic instability despite medical management. An intra-aortic balloon pump (IABP) was instituted after general anaesthesia for unresponsive systemic hypotension, along with inotropic support with noradrenaline and adrenaline. A Judkins right coronary catheter was used to cross from the femoral artery to the LV, through the larger VSD, and to the pulmonary artery. A double-length exchange terumo wire was snared in the pulmonary artery and externalized through the jugular vein, creating an arterial-venous loop. A 14Fr 65 cm Gore Dryseal long sheath was advanced from the venous side into the left ventricular outflow tract. A 37 mm GCA was chosen. To overcome the need to advance the device within the ventricle which would risk perforation, the distal extent of the device was advanced within the sheath before then unsheathing and deploying the left disc inside the LV (see , ). The LV disc was then brought back slowly onto the interventricular septum without tension and with TOE guidance. The waist and the right ventricular disc were then deployed (see , ). To keep tension off the device and to acknowledge that the apical extent of the device was only held by the free wall of the LV, the device was immediately locked. The locking loop was seen to engage the right islet.\nHypotension and significant ST elevation occurred at this point, requiring a short period of chest compressions. Transoesophageal echocardiography confirmed complete VSD coverage and suggested device stability though no stability checks were performed as the device would likely pull through and enlarge the defect given the surrounding tissue fragility (, , ). The device was released by supporting the right disc islet with the long sheath to ensure no tension was placed on the device as the retrieval cord was removed.\nThe post-procedural TTE showed complete occlusion of the defect covered by the GCA.\nThe patient was successfully extubated the following day and subsequently weaned off IABP and inotropes over the next 3 days. He recovered well and was discharged home. The device remains well-positioned on subsequent echocardiograms.", + "fulltext_subclaims": [ + "The patient was a 53-year-old male.", + "He presented with a 4-day history of worsening chest pain.", + "The pain was initially episodic left-sided non-radiating heaviness that resolved on rest.", + "In the last 24 h, the pain became constant and severe with associated sweating and shortness of breath.", + "He had no known medical conditions.", + "ECG showed inferior ST elevation with Q waves.", + "A coronary angiogram confirmed occlusion of the mid right coronary artery.", + "Aspiration thrombectomy and coronary stenting with drug-eluting stent were undertaken.", + "Complete occlusion likely occurred 24 h before presentation.", + "He was admitted to the coronary intensive care unit.", + "He remained persistently hypotensive post-procedure.", + "There was an episode of cardiac tamponade with profound hypotension secondary to a haemorrhagic pericardial effusion.", + "The haemorrhagic pericardial effusion was emergently drained 10 h after coronary revascularization.", + "Transthoracic echocardiogram and cardiac computed tomography revealed a post-myocardial infarction inferior muscular VSD.", + "There was possibly an additional smaller VSD towards the base.", + "There was an LV pseudoaneurysm due to inferior wall thinning or rupture.", + "The LV pseudoaneurysm was felt to have been the cause of the haemorrhagic effusion.", + "Percutaneous VSD closure under fluoroscopy and transoesophageal echocardiogram guidance was undertaken.", + "An intra-aortic balloon pump was instituted after general anaesthesia.", + "Inotropic support with noradrenaline and adrenaline was provided.", + "A Judkins right coronary catheter was used to cross from the femoral artery to the LV through the larger VSD.", + "A double-length exchange Terumo wire was snared in the pulmonary artery and externalized through the jugular vein.", + "A 14Fr 65 cm Gore Dryseal long sheath was advanced from the venous side into the left ventricular outflow tract.", + "A 37 mm GCA was chosen.", + "The distal extent of the device was advanced within the sheath before deployment.", + "The left disc was deployed inside the LV with TOE guidance.", + "The waist and the right ventricular disc were then deployed.", + "The device was immediately locked.", + "The locking loop was seen to engage the right islet.", + "Hypotension and significant ST elevation occurred at this point.", + "Transoesophageal echocardiography confirmed complete VSD coverage.", + "The device was released by supporting the right disc islet with the long sheath.", + "The post-procedural TTE showed complete occlusion of the defect covered by the GCA.", + "The patient was successfully extubated the following day.", + "He was weaned off IABP and inotropes over the next 3 days.", + "The device remains well-positioned on subsequent echocardiograms." + ], + "summary": "We present the occlusion of a post-myocardial infarction VSD with a GCA device in a critically ill patient at risk for closure failure and intravascular haemolysis with conventional nitinol mesh devices. The device conformed well to the anatomy even in the absence of an apical interventricular septum.", + "summary_subclaims": [ + "The patient had a post-myocardial infarction ventricular septal defect.", + "A GCA device was used for occlusion.", + "The patient was at risk for closure failure with conventional nitinol mesh devices.", + "The patient was at risk for intravascular haemolysis with conventional nitinol mesh devices.", + "The device conformed well to the anatomy.", + "There was an absence of an apical interventricular septum." + ] + }, + { + "id": "multiclinsum_test_3117_en.txt", + "fulltext": "This was a 29-year-old mother of five who presented to the Kampala International University Teaching Hospital accident and emergency department with history of difficulty swallowing, trismus and painful neck swelling for over a week. The condition had begun shortly after a tooth extraction performed by a traditional healer in the community. She had reportedly experienced progressive symptoms including fever, sharp pain, submandibular swelling, and difficulty swallowing. For which she had received two ampoules of penicillin from a nearby clinic with no improvement. She had no known chronic diseases or drug allergies.\n\nPhysical Examination\nThe patient appeared ill but not in respiratory distress. Her vital signs were: temperature: 38°C, heart rate: 85 beats/minute, blood pressure: 120/70 mmHg, respiratory rate: 15 breaths/minute and oxygen saturation at 94% on room air.\n\nHead and neck examination revealed redness and tender swelling involving the sublingual, submental, and submandibular spaces bilaterally. She exhibited trismus and could only open her mouth up to about 1.5 cm. The floor of the mouth was inflamed and elevated, and the tongue was also inflamed and swollen but did not push back far enough to obstruct the airway.\n\nDiagnostic Intervention\nDiagnostic tests revealed critical findings indicative of systemic infection. A pus culture isolated Escherichia coli and Enterococcus faecalis, with antibiotic sensitivity testing showing resistance to ceftriaxone, cefoxitin, rifampicin, amoxiclav, chloramphenicol, and azithromycin. The isolates were sensitive to ciprofloxacin, imipenem, and amikacin. Laboratory results highlighted elevated white blood cell and granulocyte counts, anemia, and thrombocytosis, reflecting the body’s response to severe infection. A contrasted CT scan was recommended, but was not done due to the patient’s financial limitations. A chest X-ray revealed cardiomegaly and features of a secondary lung infection (Pneumonia).\n\nTherapeutic Intervention\nInitial management included:\n\nAntibiotics:\n- IV Ceftriaxone 2g twice daily\n- IV Metronidazole 500mg three times daily\n- IV Gentamicin 80mg twice daily\nRehydration - Intravenous Normal Saline and Dextrose every 6 hours\n\nIntravenous paracetamol 1g three times daily for pain management\n\nSteroid Therapy – Intravenous dexamethasone 4mg TDS for 3 days.\n\nAdjusted Antibiotic regimen (post-culture sensitivity results)\n\n- IV Ciprofloxacin 400mg three times daily.\n\n- IV Metronidazole 500mg three times daily.\n\n- IV Amikacin 500mg once daily.\n\n- Imipenem was indicated as sensitive but could not be administered due to its prohibitive cost.\n\nSurgical Intervention\nMultiple incisions for drainage were performed under sedation to manage the extensive abscesses. Specifically; two incisions were made in both submandibular spaces. One incision was made in the submental area. Another incision was made in the left zygomatic area, as the swelling had extended to the left temporal area. The final incision was placed between the suitable submandibular and submental spaces. A sublingual incision was not required.\n\nThe following day, the patient reported to be feeling better, with her tongue returning to its normal position. However, we observed necrosis on her left cheek upon removing the dressing. We immediately took the patient to the operating theater and performed debridement, which revealed that the necrosis had extended to the floor of mouth, buccal mucosa, and parotid area near the division of the facial nerve. Additionally, there was a discharge from the left temporal region. Throughout these days, the patient’s vital signs remained stable, and she did not experience any respiratory distress until her final day.\n\nNecrosis Management\nThe patient developed necrosis on the left facial side, involving the submandibular space, anteromedial floor of the mouth, buccal mucosa, and posterior angle of the mandible near the facial nerve division. Debridement was performed until the necrotic tissue was cleaned. The infection seemed to extend to other deep neck spaces, evidenced by foul-smelling pus and trismus, preventing oropharynx visualization.\n\nOutcome\nThe patient’s condition deteriorated despite these interventions. On the morning of her death, there was significant bleeding from the injury site, mouth, and nose. We administered tranexamic acid (1g) in response to the bleeding, and a sample was taken to confirm DIC. She also subsequently developed respiratory distress, necessitating oxygen therapy, and a cross-matched blood transfusion was started. Preparations were made for an urgent tracheostomy in the operating theater for the possibility of difficult intubation because of the trismus. However, the patient experienced cardiorespiratory arrest on the table, and despite extensive resuscitation efforts, she succumbed to her condition.", + "fulltext_subclaims": [ + "This was a 29-year-old mother of five.", + "She presented to the Kampala International University Teaching Hospital accident and emergency department.", + "She had a history of difficulty swallowing, trismus, and painful neck swelling for over a week.", + "The condition had begun shortly after a tooth extraction performed by a traditional healer in the community.", + "She had reportedly experienced progressive symptoms including fever, sharp pain, submandibular swelling, and difficulty swallowing.", + "She had received two ampoules of penicillin from a nearby clinic with no improvement.", + "She had no known chronic diseases or drug allergies.", + "Her vital signs were: temperature: 38°C, heart rate: 85 beats/minute, blood pressure: 120/70 mmHg, respiratory rate: 15 breaths/minute, and oxygen saturation at 94% on room air.", + "Head and neck examination revealed redness and tender swelling involving the sublingual, submental, and submandibular spaces bilaterally.", + "She exhibited trismus and could only open her mouth up to about 1.5 cm.", + "The floor of the mouth was inflamed and elevated.", + "The tongue was also inflamed and swollen but did not push back far enough to obstruct the airway.", + "A pus culture isolated Escherichia coli and Enterococcus faecalis.", + "The isolates were resistant to ceftriaxone, cefoxitin, rifampicin, amoxiclav, chloramphenicol, and azithromycin.", + "The isolates were sensitive to ciprofloxacin, imipenem, and amikacin.", + "A contrasted CT scan was recommended but was not done due to the patient’s financial limitations.", + "A chest X-ray revealed cardiomegaly and features of a secondary lung infection (Pneumonia).", + "Initial management included IV Ceftriaxone 2g twice daily.", + "Initial management included IV Metronidazole 500mg three times daily.", + "Initial management included IV Gentamicin 80mg twice daily.", + "Intravenous Normal Saline and Dextrose were given every 6 hours.", + "Intravenous paracetamol 1g three times daily was used for pain management.", + "Intravenous dexamethasone 4mg TDS for 3 days was used.", + "The antibiotic regimen was adjusted post-culture sensitivity results.", + "IV Ciprofloxacin 400mg three times daily was used.", + "IV Metronidazole 500mg three times daily was used.", + "IV Amikacin 500mg once daily was used.", + "Imipenem was indicated as sensitive but could not be administered due to its prohibitive cost.", + "Multiple incisions for drainage were performed under sedation.", + "Two incisions were made in both submandibular spaces.", + "One incision was made in the submental area.", + "Another incision was made in the left zygomatic area.", + "The final incision was placed between the suitable submandibular and submental spaces.", + "A sublingual incision was not required.", + "The patient reported to be feeling better the following day.", + "The patient’s tongue returned to its normal position.", + "Necrosis was observed on her left cheek upon removing the dressing.", + "Debridement was performed.", + "The necrosis had extended to the floor of mouth, buccal mucosa, and parotid area near the division of the facial nerve.", + "There was a discharge from the left temporal region.", + "The patient’s vital signs remained stable.", + "The patient did not experience any respiratory distress until her final day.", + "The patient developed necrosis on the left facial side.", + "The necrosis involved the submandibular space, anteromedial floor of the mouth, buccal mucosa, and posterior angle of the mandible near the facial nerve division.", + "Debridement was performed until the necrotic tissue was cleaned.", + "The infection seemed to extend to other deep neck spaces.", + "The patient’s condition deteriorated despite these interventions.", + "There was significant bleeding from the injury site, mouth, and nose.", + "Tranexamic acid (1g) was administered in response to the bleeding.", + "A sample was taken to confirm DIC.", + "The patient developed respiratory distress.", + "Oxygen therapy was started.", + "A cross-matched blood transfusion was started.", + "Preparations were made for an urgent tracheostomy in the operating theater.", + "The patient experienced cardiorespiratory arrest on the table.", + "The patient succumbed to her condition." + ], + "summary": "This report describes the case of a 29-year-old female who presented to us with Ludwig’s angina following a tooth extraction performed by a traditional healer in Southwestern Uganda. The patient stayed home for over a week before she could seek formal treatment, and this delay led to severe infection and necrotizing fasciitis with extensive tissue necrosis. Despite multiple in-hospital interventions which included incision, drainage, and debridement, the patient succumbed to complications such as secondary lung infection, septicemia, and disseminated intravascular coagulation (DIC).", + "summary_subclaims": [ + "The patient was a 29-year-old female.", + "The patient presented with Ludwig’s angina.", + "The patient had a tooth extraction performed by a traditional healer.", + "The tooth extraction was performed in Southwestern Uganda.", + "The patient stayed home for over a week before seeking formal treatment.", + "The delay in treatment led to severe infection.", + "The patient developed necrotizing fasciitis.", + "The patient had extensive tissue necrosis.", + "The patient received multiple in-hospital interventions.", + "The interventions included incision, drainage, and debridement.", + "The patient succumbed to complications.", + "The complications included secondary lung infection.", + "The complications included septicemia.", + "The complications included disseminated intravascular coagulation." + ] + }, + { + "id": "multiclinsum_test_1889_en.txt", + "fulltext": "A 61-year-old male presented to the emergency department (ED) with difficulty breathing, stridor, and fever (100°Farenheit) that developed over the course of 24 hours. Laboratory studies were significant for borderline leukocytosis with elevated neutrophil count. Contrast-enhanced computed tomography (CT) of the neck demonstrated a peripherally enhancing, lobulated fluid collection with layering debris within the right paraglottic space, with external extension through the right thyrohyoid membrane and severe airway compromise .\nImaging characteristics in conjunction with the clinical findings were consistent with pyolaryngocele. Emergency tracheostomy was performed to relieve the dyspnea, followed by surgical incision and drainage of the fluid collection, which was notable for pus. The patient was discharged in stable condition and was without complication at outpatient follow-up visit.", + "fulltext_subclaims": [ + "The patient was a 61-year-old male.", + "He presented to the emergency department with difficulty breathing.", + "He had stridor.", + "He had fever of 100°Farenheit.", + "The fever developed over the course of 24 hours.", + "Laboratory studies showed borderline leukocytosis.", + "The neutrophil count was elevated.", + "Contrast-enhanced CT of the neck showed a peripherally enhancing, lobulated fluid collection.", + "The fluid collection was within the right paraglottic space.", + "The fluid collection had layering debris.", + "The fluid collection extended through the right thyrohyoid membrane.", + "There was severe airway compromise.", + "Imaging characteristics were consistent with pyolaryngocele.", + "Emergency tracheostomy was performed.", + "Surgical incision and drainage of the fluid collection was performed.", + "The fluid collection was notable for pus.", + "The patient was discharged in stable condition.", + "The patient had no complications at outpatient follow-up." + ], + "summary": "This case describes the classic imaging findings of pyolaryngocele and highlights the importance of prompt imaging for diagnosis of clinically occult airway lesions. The case also highlights how pyolaryngoceles can become large and present with acute-onset clinical symptoms, including stridor and dyspnea.", + "summary_subclaims": [ + "This case describes the classic imaging findings of pyolaryngocele.", + "The case highlights the importance of prompt imaging for diagnosis of clinically occult airway lesions.", + "The case also highlights how pyolaryngoceles can become large and present with acute-onset clinical symptoms.", + "Pyolaryngoceles can present with stridor.", + "Pyolaryngoceles can present with dyspnea." + ] + }, + { + "id": "multiclinsum_test_3210_en.txt", + "fulltext": "A 27-year-old man from Bogotá, a car parts salesman, was diagnosed with high-risk CD20+ common-type B-cell precursor acute lymphoblastic leukemia. He received two cycles of HyperCVAD and consulted the National Cancer Institute for a relapse and five-day polyarthralgia, for which he was initiated into the protocol established in 2003 by the Adult Acute Lymphoblastic Leukemia Research Group (GRAALL-2003).\n\nThe patient subsequently developed febrile neutropenia, cellulitis of the left hand without abscess, and methicillin-sensitive Staphylococcus aureus bacteremia. Cefapime and oxacillin were administered and the bacteremia resolved.\n\nOn day 21 of hospitalization, the patient presented lesions on the back of the left hand, of the type erythematoedematosa plaque, with mild and fine desquamation on the surface and central blood crust, as well as lesions in the right scapular and infra-scapular region with presence of 3 mm non-follicular papules, grouped, some erythematous and others erythemoparous, without epidermal change. The lesions were assessed by the Dermatology Service and given the characteristics of those on the back of the hand, a skin biopsy was taken for histopathological study. The results were inconclusive for the diagnosis of mycosis and no culture was done for fungi of the biopsy.\n\nDue to the persistence of the febrile neutropenia and the appearance of the skin lesions, an invasive fungal infection was suspected, and caspofungin was initiated. The chest and sinus computed tomography (CT) scans as well as the serum galactomannan detection were negative for invasive aspergillosis.\n\nHowever, despite antimicrobial and antifungal treatment, the patient did not show significant improvement, as he persisted with a fever of up to 40 °C, without other localized symptoms. The patient continued in a regular general state, sleepy, with mild mucocutaneous pallor and with 1 cm nodules, soft, depressible, painless and in the previous sites of venipuncture, without other important findings.\n\nIt was decided to take new samples for blood culture and another biopsy of the skin lesions was requested. The blood count showed a profound neutropenia (20 white blood cells per µl) and persistent lymphopenia; the C reactive protein was 6.15 mg/dl, the albumin was 1.94 g/dl and the creatinine and transaminases were normal. The control CT scan of the paranasal sinuses showed incipient chronic inflammatory changes in the right maxillary sinus; the chest CT scan was normal, but the abdomen scan documented hepatosplenomegaly.\n\nThe three blood cultures and the urine culture from day 28 of hospitalization showed yeast-like structures that were not identified in the automated panel Yeast ID (BD Phoenix™ 100). Arthroconidia were observed by microscopy and colonies compatible with Geotrichum spp. were documented, a diagnosis confirmed by matrix-assisted laser desorption ionization time-of-flight (MALDI-TOF) mass spectrometry.\n\nTreatment with amphotericin B deoxycholate was given at a daily dose of 1 mg/kg for 14 days and 400 mg/day of voriconazole for four weeks. Clinical symptoms resolved and the patient recovered from neutropenia on day 24 of the combined antifungal treatment. The patient was discharged on day 101 of hospitalisation due to clinical improvement.\n", + "fulltext_subclaims": [ + "The patient was diagnosed with high-risk CD20+ common-type B-cell precursor acute lymphoblastic leukemia.", + "The patient received two cycles of HyperCVAD.", + "The patient consulted the National Cancer Institute for a relapse and five-day polyarthralgia.", + "The patient was initiated into the protocol established in 2003 by the Adult Acute Lymphoblastic Leukemia Research Group (GRAALL-2003).", + "The patient developed febrile neutropenia.", + "The patient had cellulitis of the left hand without abscess.", + "The patient had methicillin-sensitive Staphylococcus aureus bacteremia.", + "Cefapime and oxacillin were administered.", + "The bacteremia resolved.", + "On day 21 of hospitalization, the patient presented lesions on the back of the left hand.", + "The lesions on the back of the left hand were of the type erythematoedematosa plaque.", + "The lesions on the back of the left hand had mild and fine desquamation on the surface.", + "The lesions on the back of the left hand had central blood crust.", + "The patient had lesions in the right scapular and infra-scapular region.", + "The lesions in the right scapular and infra-scapular region were 3 mm non-follicular papules.", + "The lesions in the right scapular and infra-scapular region were grouped.", + "The lesions in the right scapular and infra-scapular region were some erythematous and others erythemoparous.", + "The lesions were assessed by the Dermatology Service.", + "A skin biopsy was taken for histopathological study.", + "The results were inconclusive for the diagnosis of mycosis.", + "No culture was done for fungi of the biopsy.", + "An invasive fungal infection was suspected.", + "Caspofungin was initiated.", + "The chest and sinus computed tomography (CT) scans were negative for invasive aspergillosis.", + "The serum galactomannan detection was negative for invasive aspergillosis.", + "Despite antimicrobial and antifungal treatment, the patient did not show significant improvement.", + "The patient persisted with a fever of up to 40 °C.", + "The patient had 1 cm nodules, soft, depressible, painless and in the previous sites of venipuncture.", + "The blood count showed a profound neutropenia (20 white blood cells per µl).", + "The C reactive protein was 6.15 mg/dl.", + "The control CT scan of the paranasal sinuses showed incipient chronic inflammatory changes in the right maxillary sinus.", + "The abdomen scan documented hepatosplenomegaly.", + "The three blood cultures and the urine culture from day 28 of hospitalization showed yeast-like structures.", + "The yeast-like structures were not identified in the automated panel Yeast ID (BD Phoenix™ 100).", + "Arthroconidia were observed by microscopy.", + "Colonies compatible with Geotrichum spp. were documented.", + "The diagnosis was confirmed by matrix-assisted laser desorption ionization time-of-flight (MALDI-TOF) mass spectrometry.", + "Treatment with amphotericin B deoxycholate was given at a daily dose of 1 mg/kg for 14 days.", + "400 mg/day of voriconazole was given for four weeks.", + "Clinical symptoms resolved.", + "The patient recovered from neutropenia on day 24 of the combined antifungal treatment.", + "The patient was discharged on day 101 of hospitalisation due to clinical improvement." + ], + "summary": "A 27-year-old male with a relapsed acute lymphoblastic leukemia presented with five-day-old polyarthralgia. He also had febrile neutropenia, cellulitis without abscesses, and methicillin-resistant Staphylococcus aureus bacteremia for which he received therapy with oxacillin and cefepime. However, the febrile neutropenia persisted, and an invasive fungal infection was suspected. A new set of blood cultures was taken and antifungal treatment was initiated. Arthroconidia were identified in the blood cultures and a matrix-assisted laser desorption ionization-mass spectrometry confirmed the presence of Geotrichum spp. Antifungal treatment was adjusted to 14 days of deoxycholate amphotericin B and four weeks of voriconazole. After a prolonged stay, he was discharged.\n", + "summary_subclaims": [ + "The patient is a 27-year-old male.", + "The patient has relapsed acute lymphoblastic leukemia.", + "The patient had five-day-old polyarthralgia.", + "The patient had febrile neutropenia.", + "The patient had cellulitis without abscesses.", + "The patient had methicillin-resistant Staphylococcus aureus bacteremia.", + "The patient received therapy with oxacillin and cefepime.", + "The febrile neutropenia persisted.", + "An invasive fungal infection was suspected.", + "A new set of blood cultures was taken.", + "Antifungal treatment was initiated.", + "Arthroconidia were identified in the blood cultures.", + "Matrix-assisted laser desorption ionization-mass spectrometry confirmed the presence of Geotrichum spp.", + "Antifungal treatment was adjusted to 14 days of deoxycholate amphotericin B.", + "Antifungal treatment was adjusted to four weeks of voriconazole.", + "The patient was discharged after a prolonged stay." + ] + }, + { + "id": "multiclinsum_test_2628_en.txt", + "fulltext": "We report the case of a 58-year-old woman diagnosed with multiple simultaneous colon cancer using the Pillcam Colon 2. The patient referred to our service for dyspnea, fatigue and chest pain with a progressive onset. From patient history, we should mention type II diabetes mellitus, atrial fibrillation and cardiac ischemic disease and family history of colon cancer (father). She received a low dose of aspirin (Aspenter 75mg). The patient denied melena or changes of bowel habits.\nOn examination, the patient was noted to be pale, tachycardic (pulse = 104 bpm), orthopneic, with pulmonary rales, tender liver and periferal pitting edema; gynecologic evaluation was normal. Blood tests showed severe hypochromic-microcytic anemia (hemoglobin = 7,61g/dl; MCV=66,2fl; MCH=19,8pg), thrombocytosis (PLT= 500.000/mmc) with low level of serum Fe (19 microg/dl) and high Fe-binding capacity (495 mg/dl). Renal function tests revealed a minimally elevated BUN (51mg/dl). Other biochemical markers found some inflammatory activity (ESR = 50mm/h, CRP +), while tumoral markers were non-reactive. Upper endoscopy revealed an erosive pangastritis (probably due to aspirin ingestion) with no evidence of bleeding. This is why we decided to perform a colonoscopy, but because of the associated co-morbidities, the patient could not tolerate the examination. We used the Pillcam colon 2 system to investigate the entire digestive tract. The patient underwent a special preparation regimen with 6L of PEG (2L one day before capsule ingestion, 2L in the same day before ingestion and 2L after ingestion). This revealed one tumoral mass in the caecum and a second tumor in the transverse colon . After blood transfusions (2 MER units) and improvement of cardiac function, the patient was transferred in a surgery unit and two days later, she underwent surgery. Because the preoperative CT scan found no metastatic lesions and lymph nodes, there was no need for chemotherapy. The follow-up at 3 and 6 months after surgery identified no early complications or tumor recurrence.", + "fulltext_subclaims": [ + "The patient was a 58-year-old woman.", + "The patient was diagnosed with multiple simultaneous colon cancer using the Pillcam Colon 2.", + "The patient referred to the service for dyspnea, fatigue, and chest pain with a progressive onset.", + "The patient had a history of type II diabetes mellitus.", + "The patient had a history of atrial fibrillation.", + "The patient had a history of cardiac ischemic disease.", + "The patient had a family history of colon cancer (father).", + "The patient received a low dose of aspirin (Aspenter 75mg).", + "The patient denied melena.", + "The patient denied changes of bowel habits.", + "On examination, the patient was noted to be pale.", + "On examination, the patient was noted to be tachycardic (pulse = 104 bpm).", + "On examination, the patient was noted to be orthopneic.", + "On examination, pulmonary rales were present.", + "On examination, the liver was tender.", + "On examination, peripheral pitting edema was present.", + "Blood tests showed severe hypochromic-microcytic anemia (hemoglobin = 7,61g/dl; MCV=66,2fl; MCH=19,8pg).", + "Blood tests showed thrombocytosis (PLT= 500.000/mmc).", + "Blood tests showed a low level of serum Fe (19 microg/dl).", + "Blood tests showed high Fe-binding capacity (495 mg/dl).", + "Renal function tests revealed a minimally elevated BUN (51mg/dl).", + "Inflammatory activity was indicated by ESR = 50mm/h and CRP +.", + "Tumoral markers were non-reactive.", + "Upper endoscopy revealed an erosive pangastritis.", + "Upper endoscopy found no evidence of bleeding.", + "A colonoscopy was decided upon.", + "The patient could not tolerate the colonoscopy due to associated co-morbidities.", + "The Pillcam colon 2 system was used to investigate the entire digestive tract.", + "The patient underwent a special preparation regimen with 6L of PEG.", + "The Pillcam revealed one tumoral mass in the caecum.", + "The Pillcam revealed a second tumor in the transverse colon.", + "The patient received blood transfusions (2 MER units).", + "The patient was transferred to a surgery unit after improvement of cardiac function.", + "The patient underwent surgery two days after transfer.", + "The preoperative CT scan found no metastatic lesions.", + "The preoperative CT scan found no lymph nodes.", + "There was no need for chemotherapy.", + "The follow-up at 3 and 6 months after surgery identified no early complications.", + "The follow-up at 3 and 6 months after surgery identified no tumor recurrence." + ], + "summary": "We present the case of a 58-year-old patient, with severe anemia caused by bleeding from a gastrointestinal source. The patient was diabetic, hypertensive and with impaired heart function, aggravated by anemia. We used the Pillcam Colon 2 capsule to investigate the colon and we found 2 tumors in the cecum and transverse colon.", + "summary_subclaims": [ + "The patient was 58 years old.", + "The patient had severe anemia.", + "The anemia was caused by bleeding from a gastrointestinal source.", + "The patient was diabetic.", + "The patient was hypertensive.", + "The patient had impaired heart function.", + "The heart function was aggravated by anemia.", + "We used the Pillcam Colon 2 capsule to investigate the colon.", + "We found 2 tumors.", + "One tumor was in the cecum.", + "One tumor was in the transverse colon." + ] + }, + { + "id": "multiclinsum_test_3392_en.txt", + "fulltext": "A previously healthy, 17-year-old white American female individual with a noncontributable past medical history brought to an outpatient pediatric clinic by her mother in January with an erythematous rash on the anterior aspect of her neck with overlying vesicles. The rash had been present for 2 days, and she described it as cramping, tingling, and itchy but denied headaches, nausea, vomiting, fevers, myalgias or arthralgias. She has no known sick contacts and no other lesions or rashes. She denied addition of new foods, supplements, skin care products, or detergents. She did not take any prescriptions or supplements and had no known allergies. She completed all her vaccination series as recommended by the CDC schedule. She did not have a reaction after either of her varicella vaccinations. Family history is notable for a brother with keratosis pilaris, a mother with plaque psoriasis, and a cousin that had a case of varicella shortly after his initial varicella vaccination. Physical examination showed vesicular lesions overlying an erythematous base on the anterior neck with various vesicular macules of various diameters in the C2 and V3 dermatomal distributions. Bilateral tympanic membranes and external ear canals were without lesions. No ocular involvement was detected; extraocular eye motion was intact, and pupils were equal and reactive to light. At that time, she was prescribed 1 g oral valacyclovir to be taken every 8 hours for seven days and topical 5% acyclovir with bacitracin 500 U/g to be applied every 12 hours for seven days for the diagnosis of probable VZV on the basis of the appearance of the lesions.\n\nLaboratory tests were drawn and ordered at the time of her initial visit to confirm this diagnosis, including a C-reactive protein (CRP), complete blood count (CBC), erythrocyte sedimentation rate (ESR), cytomegalovirus (CMV) immunoglobulin (Ig)G antibodies, VZV IgM and IgG antibodies and viral load, herpes simplex virus (HSV) 1 and 2 viral load, monkeypox viral load, and Epstein–Barr virus (EBV) profile. The only abnormalities were a VZV IgG level of 1304 (reference range: positive > 165) and a VZV viral load of 3.8 billion copies/mL, representative of a high viral load. VZV IgM antibodies were negative, as were the other viral load levels. Her CBC, CRP, and ESR were within normal limits.\n\nA total of 1 day after being seen in clinic, she presented to the emergency department owing to development of a fever, nausea and vomiting overnight. There, she had a temperature of 103.1 °F, blood pressure of 128/74, pulse of 87, respiratory rate of 17, and oxygen saturation of 97% on room air. They noted a vesicular rash and erythema extending from under the left ear to the left face and neck, with a notable spread from the C2 and V3 dermatome to the V2 dermatome. There was no rash on the tip of the nose or in the ear canal but there was a small vesicle near the left eye. She was discharged home with acetaminophen 1000 mg and hydrocodone/acetaminophen 5 mg/325 mg as needed for the pain. No labs or imaging were performed.\n\nA total of 2 days after the initial clinic visit, the patient reported new-onset lethargy. The rash was still within the V2, V3, and C2 dermatomes. Pediatric infectious disease was consulted at this time. They suggested the addition of swabbing for group A strep owing to the possibility of underlying bacterial skin infection, as well as HIV blood test, both of which were negative.\n\nA total of 1 week after the onset of the rash, she was seen in the clinic. At this time, she had been taking the oral valacyclovir and using the topical acyclovir for 5 days. Her vitals were within normal limits; she no longer had a fever, nausea, vomiting, headache, or lethargy. On physical exam, the vesicles were present in the V2, V3, and C2 dermatome and had begun to scab over; they were no longer burning or cramping but remained itchy. There were no new lesions or rashes and she did not demonstrate any vision changes, hearing loss, or focal neurological deficits. Labs were redrawn at this time; CBC and HIV remained within normal limits. Varicella viral load was undetectable at this time. On follow up, the patient reported complete recovery of the vesicular rash within 2 weeks of beginning antiviral treatment. She has no residual scarring or symptoms.", + "fulltext_subclaims": [ + "The patient is a 17-year-old white American female.", + "She was brought to an outpatient pediatric clinic by her mother.", + "The rash had been present for 2 days.", + "The rash was on the anterior aspect of her neck with overlying vesicles.", + "She described the rash as cramping, tingling, and itchy.", + "She denied headaches, nausea, vomiting, fevers, myalgias, or arthralgias.", + "She had no known sick contacts.", + "She denied addition of new foods, supplements, skin care products, or detergents.", + "She did not take any prescriptions or supplements.", + "She had no known allergies.", + "She completed all her vaccination series as recommended by the CDC schedule.", + "She did not have a reaction after either of her varicella vaccinations.", + "Physical examination showed vesicular lesions overlying an erythematous base on the anterior neck.", + "The lesions were in the C2 and V3 dermatomal distributions.", + "She was prescribed 1 g oral valacyclovir every 8 hours for seven days.", + "She was prescribed topical 5% acyclovir with bacitracin 500 U/g every 12 hours for seven days.", + "The diagnosis was probable VZV on the basis of the appearance of the lesions.", + "Laboratory tests included VZV IgM and IgG antibodies and viral load.", + "The VZV IgG level was 1304.", + "The VZV viral load was 3.8 billion copies/mL.", + "VZV IgM antibodies were negative.", + "The other viral load levels were negative.", + "Her CBC, CRP, and ESR were within normal limits.", + "One day after the initial clinic visit, she presented to the emergency department.", + "She had a temperature of 103.1 °F.", + "The rash extended from under the left ear to the left face and neck.", + "There was a small vesicle near the left eye.", + "She was discharged home with acetaminophen 1000 mg and hydrocodone/acetaminophen 5 mg/325 mg as needed for the pain.", + "Two days after the initial clinic visit, the patient reported new-onset lethargy.", + "Pediatric infectious disease suggested swabbing for group A strep.", + "The group A strep swab was negative.", + "An HIV blood test was negative.", + "One week after the onset of the rash, she was seen in the clinic.", + "She had been taking oral valacyclovir and using topical acyclovir for 5 days.", + "The vesicles had begun to scab over.", + "The vesicles were no longer burning or cramping but remained itchy.", + "There were no new lesions or rashes.", + "Varicella viral load was undetectable.", + "On follow up, the patient reported complete recovery of the vesicular rash within 2 weeks of beginning antiviral treatment.", + "She has no residual scarring or symptoms." + ], + "summary": "This report presents a case of herpes zoster in a fully vaccinated 17-year-old white American female, highlighting the importance of considering herpes zoster in immunocompetent, vaccinated children. The patient presented with a rash along multiple dermatomes, which spread despite antiviral treatment. After completion of the antiviral treatment, the rash eventually receded, and she was left with no residual symptoms.", + "summary_subclaims": [ + "This report presents a case of herpes zoster in a fully vaccinated 17-year-old white American female.", + "The patient presented with a rash along multiple dermatomes.", + "The rash spread despite antiviral treatment.", + "After completion of the antiviral treatment, the rash eventually receded.", + "She was left with no residual symptoms." + ] + }, + { + "id": "multiclinsum_test_2764_en.txt", + "fulltext": "A 21-year-old woman presented with left upper quadrant pain. She underwent routine blood tests and non-contrast computed tomography (CT). The blood tests did not show any abnormalities, and the CT showed the presence of three, similarly sized spleens, but no other abnormalities. As the patient did not have any other symptoms, she was sent home with a prescription for an analgesic. However, the abdominal pain did not improve and she returned to the hospital 2 days later. Her inflammatory markers were somewhat elevated, and an enhanced CT showed that one of the multiple spleens did not pick up the contrast . We diagnosed her with splenic infarction; however, the cause of the infarction was unclear, and torsion or embolism was considered possibilities. The patient was admitted and began conservative therapy, including fasting and antibiotic administration. However, neither her abdominal pain nor inflammatory marker levels improved . Hence, we performed a follow-up enhanced-CT scan, 2 days after admission, which showed that the splenic infarction had not improved and that ascitic fluid was present around the spleen and in the pelvic space . At this point, we decided to surgically remove the infarcted spleen. Considering that the patient was a young woman, we elected to perform a laparoscopic splenectomy after receiving informed consent.\nThe surgery was performed under general anesthesia, with the patient in a supine position and her legs spread apart. We created an umbilical incision and inserted three operating ports along the left subcostal margin (5 mm, 12 mm, and 5 mm in size), and a 5-mm operating port on the left side of the abdomen . The port sites were selected along the lines of a left subcostal incision, in case conversion to open surgery became necessary. These port sites were also in a co-axial position to the surgeon. There were no adhesions observed in the abdominal cavity. First, we incised the omentum and opened the bursa, detecting two non-infarcted spleens in front of the pancreas. Behind these spleens, there was an infarcted spleen surrounded by fluid. We incised the inflamed adipose tissue around the spleen to expose the pedicle, which was twisted; consequently, we diagnosed splenic torsion . Using an automatic suturing device, we dissected the pedicle of the infarcted spleen. The umbilical incision was extended to remove the resected spleen (78 × 57 × 35 mm) . After confirming the absence of active bleeding, we sutured the incisions. The surgical time was 119 min, and there was little blood loss. The patient did not experience any complications and was discharged 4 days after surgery.", + "fulltext_subclaims": [ + "The patient was a 21-year-old woman.", + "She presented with left upper quadrant pain.", + "She underwent routine blood tests.", + "She underwent non-contrast computed tomography (CT).", + "The blood tests did not show any abnormalities.", + "The CT showed the presence of three, similarly sized spleens.", + "The CT showed no other abnormalities.", + "The patient did not have any other symptoms.", + "She was sent home with a prescription for an analgesic.", + "The abdominal pain did not improve.", + "She returned to the hospital 2 days later.", + "Her inflammatory markers were somewhat elevated.", + "An enhanced CT showed that one of the multiple spleens did not pick up the contrast.", + "We diagnosed her with splenic infarction.", + "The cause of the infarction was unclear.", + "Torsion or embolism was considered possibilities.", + "The patient was admitted.", + "She began conservative therapy.", + "Conservative therapy included fasting.", + "Conservative therapy included antibiotic administration.", + "Neither her abdominal pain nor inflammatory marker levels improved.", + "We performed a follow-up enhanced-CT scan 2 days after admission.", + "The follow-up enhanced-CT scan showed that the splenic infarction had not improved.", + "Ascitic fluid was present around the spleen.", + "Ascitic fluid was present in the pelvic space.", + "We decided to surgically remove the infarcted spleen.", + "The patient was a young woman.", + "We elected to perform a laparoscopic splenectomy.", + "We received informed consent.", + "The surgery was performed under general anesthesia.", + "The patient was in a supine position.", + "The patient's legs were spread apart.", + "We created an umbilical incision.", + "We inserted three operating ports along the left subcostal margin.", + "The ports were 5 mm, 12 mm, and 5 mm in size.", + "We inserted a 5-mm operating port on the left side of the abdomen.", + "The port sites were selected along the lines of a left subcostal incision.", + "The port sites were in a co-axial position to the surgeon.", + "There were no adhesions observed in the abdominal cavity.", + "We incised the omentum.", + "We opened the bursa.", + "We detected two non-infarcted spleens in front of the pancreas.", + "Behind these spleens, there was an infarcted spleen surrounded by fluid.", + "We incised the inflamed adipose tissue around the spleen.", + "We exposed the pedicle, which was twisted.", + "We diagnosed splenic torsion.", + "We dissected the pedicle of the infarcted spleen using an automatic suturing device.", + "The umbilical incision was extended to remove the resected spleen.", + "The resected spleen was 78 × 57 × 35 mm.", + "After confirming the absence of active bleeding, we sutured the incisions.", + "The surgical time was 119 min.", + "There was little blood loss.", + "The patient did not experience any complications.", + "The patient was discharged 4 days after surgery." + ], + "summary": "A 21-year-old woman presented with left upper quadrant pain, the cause of which could not be diagnosed. She returned to our hospital, 2 days later, without any pain improvement. Enhanced computed tomography showed splenic infarction and polysplenia. Initially, we could not identify the cause of the infarction and started conservative therapy, which did not result in any improvement. Hence, we performed a splenectomy, after securing informed consent. Because the patient was a young woman, we opted for a laparoscopic approach. During surgery, we identified the cause of the infarction as spleen pedicle torsion; the infarcted spleen was excised using an automated suturing device. We completed the laparoscopic surgery without converting it to an open laparotomy, and the patient was discharged 4 days later. This was a rare case of polysplenia with splenic torsion.", + "summary_subclaims": [ + "The patient was a 21-year-old woman.", + "She presented with left upper quadrant pain.", + "The cause of the pain could not be diagnosed.", + "She returned to the hospital 2 days later.", + "She had no improvement in pain.", + "Enhanced computed tomography showed splenic infarction.", + "Enhanced computed tomography showed polysplenia.", + "The cause of the infarction could not be identified initially.", + "Conservative therapy was started.", + "Conservative therapy did not result in any improvement.", + "A splenectomy was performed after securing informed consent.", + "The patient was a young woman.", + "A laparoscopic approach was opted for.", + "During surgery, the cause of the infarction was identified as spleen pedicle torsion.", + "The infarcted spleen was excised using an automated suturing device.", + "The laparoscopic surgery was completed without converting to an open laparotomy.", + "The patient was discharged 4 days after surgery.", + "This was a rare case of polysplenia with splenic torsion." + ] + }, + { + "id": "multiclinsum_test_1810_en.txt", + "fulltext": "It was a second pregnancy of 34-year-old women with obesity and primary hypertension. High blood pressure of maximum values 170/100 mmHg was treated with methyldopa in increasing doses, trimetazidinie, dihydrochloride and low dosage acetylic acid. Ultrasound exam at the 13th week of gestation was normal with NT 2,2 mm, and at 20 weeks of gestation there was reported normal fetal biometry and normal heart anatomy. At the age of 34th week of pregnancy, woman was admitted to hospital because of high blood pressure and abnormal Doppler flow in fetus. No echocardiography exam was available. Antenatal corticosteroids were given once three days before birth with magnesium sulfate for fetal neuroprotection and lung development stimulation.\nIn a district hospital, a male neonate was born at 34 weeks of gestational age by C-section because of increased risk for birth asphyxia, based on abnormal cardiotocography (CTG) tracing .\nThe preterm boy had birth weight 2600 g and had head circumference and length in normal values range of 50–90 centiles. Due to respiratory distress syndrome, nasal Duo positive airway pressure was performed for the first two days of postnatal life. The chest x-ray excluded pneumonitis, the heart size was in normal values. Laboratory findings show increasing C-reactive protein concentrations in the following days. A third day at the physical exam, his heart rate was 220/bpm. ECG has shown the supraventricular tachycardia with a narrow QRS atrial rate (AR) was equal to ventricular (VR) and was 220/min. Adenosine was administered twice- first dose 0,15 mg/kg, second dose 0,25 mg/kg. But arrhythmia remained resistant to these therapies. However, ECG detected for a short time atrial tachycardia (atrial rate 420/min, ventricular rate 45-65-70/min). Therefore, amiodarone therapy was started- 5 mg/kg. Echocardiography revealed patent foramen ovale, tricuspid valve regurgitation with a 29 mmHg gradient and mild mitral regurgitation. The ejection fraction (EF) was 62%. Because of unsuccessful treatment, the newborn was transferred from the district hospital to hospital with a Paediatric Cardiology Department on day 3. Next ECG demonstrated supraventricular tachycardia with narrow QRS (220/min) . The administration of adenosine (0,1 mg/kg) resulted in the obvious appearance of “sawtooth wave” typical for AFL . After a while, ECG demonstrated supraventricular tachycardia (SVT), exactly 3:1 atrioventricular conduction AFL (atrial rate 500/bpm, ventricular rate 250/bpm). Due to the recurrence of AFL, cardioversion was performed with 1 J/kg and the rhythm converted to normal. Amiodarone therapy with a dosage of 15 mg/kg/day was started as a prophylaxis against recurrent arrhythmia attacks. After 24 h without the AFL attack, intravenous amiodarone therapy was replaced with oral treatment. SVT did not occur and the infant was discharged on the 23rd day of life in a good general state with amiodarone oral therapy. AFL did not repeat in the 1-year follow up and corrected QT (QTc), Holter ECG and echocardiography (ECHO) were all found to be normal. Therefore, therapy was stopped.", + "fulltext_subclaims": [ + "It was a second pregnancy of a 34-year-old woman with obesity and primary hypertension.", + "High blood pressure of maximum values 170/100 mmHg was treated with methyldopa in increasing doses.", + "Ultrasound exam at the 13th week of gestation was normal with NT 2.2 mm.", + "At 20 weeks of gestation, there was reported normal fetal biometry and normal heart anatomy.", + "At the age of 34 weeks of pregnancy, the woman was admitted to hospital because of high blood pressure and abnormal Doppler flow in fetus.", + "Antenatal corticosteroids were given once three days before birth.", + "A male neonate was born at 34 weeks of gestational age by C-section.", + "The preterm boy had birth weight 2600 g.", + "Due to respiratory distress syndrome, nasal Duo positive airway pressure was performed for the first two days of postnatal life.", + "The chest x-ray excluded pneumonitis.", + "The heart size was in normal values.", + "Laboratory findings showed increasing C-reactive protein concentrations in the following days.", + "On the third day, his heart rate was 220/bpm.", + "ECG showed supraventricular tachycardia with a narrow QRS.", + "Adenosine was administered twice—first dose 0.15 mg/kg, second dose 0.25 mg/kg.", + "Arrhythmia remained resistant to these therapies.", + "ECG detected for a short time atrial tachycardia with atrial rate 420/min.", + "Amiodarone therapy was started—5 mg/kg.", + "Echocardiography revealed patent foramen ovale.", + "Echocardiography showed tricuspid valve regurgitation with a 29 mmHg gradient.", + "Echocardiography showed mild mitral regurgitation.", + "The ejection fraction was 62%.", + "The newborn was transferred from the district hospital to hospital with a Paediatric Cardiology Department on day 3.", + "Next ECG demonstrated supraventricular tachycardia with narrow QRS (220/min).", + "The administration of adenosine (0.1 mg/kg) resulted in the obvious appearance of “sawtooth wave” typical for AFL.", + "ECG demonstrated supraventricular tachycardia with 3:1 atrioventricular conduction AFL.", + "Cardioversion was performed with 1 J/kg and the rhythm converted to normal.", + "Amiodarone therapy with a dosage of 15 mg/kg/day was started as a prophylaxis against recurrent arrhythmia attacks.", + "After 24 h without the AFL attack, intravenous amiodarone therapy was replaced with oral treatment.", + "SVT did not occur and the infant was discharged on the 23rd day of life in a good general state with amiodarone oral therapy.", + "AFL did not repeat in the 1-year follow up.", + "Corrected QT (QTc), Holter ECG and echocardiography (ECHO) were all found to be normal.", + "Therapy was stopped." + ], + "summary": "We report a case of a neonate who was born at 34 weeks of gestational age by C-section because of risk for birth asphyxia, based on abnormal CTG tracing, which had no characteristic rhythms for fetal decelerations. A third day his heart rate was 220/bpm. ECG has shown supraventricular tachycardia with narrow QRS. The administration of adenosine resulted in the obvious appearance of \"sawtooth wave\" typical for AFL. Arrhythmia was resistant to the therapy of amiodaron. Then cardioversion was performed and the rhythm converted to normal.", + "summary_subclaims": [ + "The neonate was born at 34 weeks of gestational age.", + "The neonate was born by C-section.", + "The C-section was performed because of risk for birth asphyxia.", + "The risk for birth asphyxia was based on abnormal CTG tracing.", + "The CTG tracing had no characteristic rhythms for fetal decelerations.", + "On the third day, the neonate's heart rate was 220/bpm.", + "ECG showed supraventricular tachycardia with narrow QRS.", + "The administration of adenosine resulted in the obvious appearance of 'sawtooth wave' typical for AFL.", + "Arrhythmia was resistant to the therapy of amiodaron.", + "Cardioversion was performed.", + "The rhythm converted to normal." + ] + }, + { + "id": "multiclinsum_test_729_en.txt", + "fulltext": "A 64-year-old white European man presented with right knee pain due to an isolated medial meniscal tear of non-traumatic origin, confirmed on X-ray and computed tomography (CT) arthrogram . An arthroscopic partial medial meniscectomy was performed and in the same session a grade 1a International Cartilage Repair Society (ICRS) cartilaginous lesion was revealed. His early postoperative course was favorable, without fever or other signs of infection. Unfortunately, his knee pain reappeared 2 months postoperatively and became invalidating within the following month, leading to another set of X-rays (anterior-posterior and lateral) that showed complete medial femorotibial joint thinning. A clinical examination showed neither effusion nor redness; he had a good range of motion (0/0/125°), no laxity, a slight varus morphology and anterior medial femorotibial pain with no meniscal pain. The X-rays were completed by a schuss view that confirmed an Ahlbäck stage III joint thinning and a CT arthrogram showed complete chondrolysis of his medial femorotibial compartment . Standing long leg films showed an 8° varus deviation compared to 3° on his left knee. All blood work was normal, and no rheumatologic cause was identified. No genetic testing was performed. As there was no argument for infection, no aspiration was performed. Infiltration and viscosupplementation were proposed but refused by the patient. He is now waiting for a unicompartmental knee replacement.", + "fulltext_subclaims": [ + "A 64-year-old white European man presented with right knee pain due to an isolated medial meniscal tear of non-traumatic origin.", + "The medial meniscal tear was confirmed on X-ray and computed tomography (CT) arthrogram.", + "An arthroscopic partial medial meniscectomy was performed.", + "A grade 1a International Cartilage Repair Society (ICRS) cartilaginous lesion was revealed during the same session.", + "The early postoperative course was favorable, without fever or other signs of infection.", + "Knee pain reappeared 2 months postoperatively.", + "The knee pain became invalidating within the following month.", + "X-rays showed complete medial femorotibial joint thinning.", + "Clinical examination showed neither effusion nor redness.", + "He had a good range of motion (0/0/125°).", + "He had no laxity.", + "He had a slight varus morphology.", + "He had anterior medial femorotibial pain with no meniscal pain.", + "A schuss view confirmed an Ahlbäck stage III joint thinning.", + "A CT arthrogram showed complete chondrolysis of his medial femorotibial compartment.", + "Standing long leg films showed an 8° varus deviation compared to 3° on his left knee.", + "All blood work was normal.", + "No rheumatologic cause was identified.", + "No genetic testing was performed.", + "No aspiration was performed.", + "Infiltration and viscosupplementation were proposed but refused by the patient.", + "He is now waiting for a unicompartmental knee replacement." + ], + "summary": "A 64-year-old white European man presented with right knee pain due to a medial meniscal tear with no other abnormality found on examination or imaging. An arthroscopic partial medial meniscectomy was performed and early evolution was favorable with no signs of infection. He developed knee pain 2 months later. X-rays showed a thinning of the medial compartment which was confirmed by computed tomography arthrogram. There was no articular effusion, mobility was conserved (0/0/125°), there was no laxity, and pain was localized to the medial femorotibial compartment, with no meniscal signs. There was a 8° varus deviation (versus 3° for his uninjured left knee). His blood work was normal. As there were no signs of infection, no aspiration was performed. Viscosupplementation was offered but refused by the patient. He is now waiting for a partial knee replacement.", + "summary_subclaims": [ + "The patient is a 64-year-old white European man.", + "He presented with right knee pain due to a medial meniscal tear.", + "No other abnormality was found on examination or imaging.", + "An arthroscopic partial medial meniscectomy was performed.", + "Early evolution was favorable with no signs of infection.", + "He developed knee pain 2 months later.", + "X-rays showed a thinning of the medial compartment.", + "Computed tomography arthrogram confirmed the thinning of the medial compartment.", + "There was no articular effusion.", + "Mobility was conserved at 0/0/125°.", + "There was no laxity.", + "Pain was localized to the medial femorotibial compartment.", + "There were no meniscal signs.", + "There was an 8° varus deviation.", + "His blood work was normal.", + "As there were no signs of infection, no aspiration was performed.", + "Viscosupplementation was offered but refused by the patient.", + "He is now waiting for a partial knee replacement." + ] + }, + { + "id": "multiclinsum_test_776_en.txt", + "fulltext": "A 66-year-old woman, with a WHO performance status of 0, history of chronic smoking, high blood pressure and atrial fibrillation, was diagnosed with a stage IVa locally advanced laryngeal squamous-cell carcinoma (cT3N2M0). She had neither history of headache nor previous allergic drug reactions. She received neoadjuvant chemotherapy by docetaxel, cisplatin and fluorouracil, with a marked tumor regression following three courses. She was then offered definitive external beam radiotherapy with concurrent weekly cetuximab. On her first cycle, she received routine premedication with dexchlorpheniramine 5 mg I.V. followed by a loading dose of 400 mg/m2 cetuximab I.V. over 2 h (5 mg/min) without developing any infusion reaction. Her usual medicines were rilmenidine, pantoprazole, fenofibrate, and acetaminophen. However, 4 h after completing cetuximab infusion, she was admitted to hospital with sudden headaches, photophobia, neck stiffness and vomiting without fever.\nCerebrospinal fluid (CSF) analysis showed a cloudy liquid with elevated protein (1.5 g/L; normal range: 0.2–0.4 g/L), a red blood cell count of 6/μL, and a leukocyte count of 4100/μL (normal range: 0–4/μL), 90 % of them were neutrophils, 9 % were lymphocytes, and 1 % were monocytes. The glucose level in CSF was 3.16 mM (normal range: 2.7–4.2 mM) with a glucose level in blood of 7.3 mM (ratio 0.43). The white blood cell count was 7900/μL with 7000/μL neutrophils, and a C-reactive protein at 5.9 mg/L (normal range <6.0 mg/L). The patient was treated with empiric antibiotic therapy (ceftriaxone I.V.) for 7 days without corticosteroids and recovered neurologically within 8 days. Bacterial cultures remained negative. Viral analysis including a viral encephalitis panel was performed by polymerase chain reaction and remained negative. Repeat CSF analysis was initially planned 8 days after admission to the hospital but the lumbar puncture failed and was not repeated as the patient was well.\nSymptoms resolution was reported by day 2. Radiation therapy was started 3 weeks after for 8 weeks and cetuximab was reintroduced 28 days after with a lower dose of 250 mg/m2. Methylprednisolone 80 mg I.V. was added to dexchlorpheniramine 5 mg I.V. and the infusion flow rate of cetuximab was decreased to 2 mg/min. She tolerated it well and no side effects were reported all along the other additional infusions up to 10 weeks. At a follow-up of 18 months the patient is well with no evidence of tumor recurrence.\nThe temporal association, clinical and laboratory findings strongly support the diagnosis of cetuximab-induced aseptic meningitis. As for our patient, most patients with aseptic meningitis are treated with antibiotics, pending identification of infectious agent and recover within 2 weeks, without any long-term neurological sequelae.\nDistinction on clinical grounds alone is not possible, and the CSF pattern with neutrophilic pleocytosis may cause confusion with infectious meningitis. Resolution occurs several days after drug discontinuation. Diagnosis of aseptic meningitis is based on viral and bacterial CSF profiles remaining sterile.\nNonsteroidal anti-inflammatory drugs, antibiotics, intravenous immunoglobulins, antiepileptic drugs, and monoclonal antibodies (mainly tumor necrosis factor inhibitors) are the most frequent cause of drug-induced meningitis. History of drug intake is crucial because there are no specific characteristics associated with a specific drug .\nIn order to try to understand the pathophysiology of aseptic meningitis due to cetuximab, we can draw similarities with aseptic meningitis occurring with I.V. immunoglobulin (IVIG) infusion [–]. The factors, which may predispose to the development of the meningitis, include fast infusion rates and a history of headaches. The symptoms of aseptic meningitis generally occur within 24 h of starting treatment. Theories of aseptic meningitis with IVIG have included an allergic hypersensitivity reaction or serum immunoglobulin crossing the blood brain barrier. Hence, this entry of serum immunoglobulin into the cerebrospinal fluid would be responsible for the inflammatory reaction. It has also been suggested that releasing histamine, serotonin, and prostaglandins could affect the meningeal microvasculature, such as in migraine mechanism .\nThe first occurrence of drug-induced aseptic meningitis related to cetuximab was reported in 2000 by Baselga et al. in a phase I clinical trial . Since then, 7 other cases of cetuximab-induced aseptic meningitis have been described. Cetuximab was reintroduced successfully for three of them with an appropriate premedication and a slower infusion rate, one patient had a positive rechallenge without corticosteroid premedication [, ]. Characteristics of the reported patients from the literature were compiled recently and are now completed with a new one and our present report in Table . Note that these adverse reactions always occurred during the first administration which may suggest a dose-related response, even though an idiosyncratic response in patients with risk factors is also possible. Surprisingly, there are no cases described in colorectal cancer whereas cetuximab is commonly being dosed at 500 mg/m2 (higher dose) every 2 weeks for a larger number of patients.", + "fulltext_subclaims": [ + "The patient was a 66-year-old woman.", + "She had a WHO performance status of 0.", + "She had a history of chronic smoking.", + "She had a history of high blood pressure.", + "She had a history of atrial fibrillation.", + "She was diagnosed with stage IVa locally advanced laryngeal squamous-cell carcinoma (cT3N2M0).", + "She had no history of headache.", + "She had no previous allergic drug reactions.", + "She received neoadjuvant chemotherapy with docetaxel, cisplatin, and fluorouracil.", + "She had marked tumor regression after three courses of neoadjuvant chemotherapy.", + "She was offered definitive external beam radiotherapy with concurrent weekly cetuximab.", + "On her first cycle, she received routine premedication with dexchlorpheniramine 5 mg I.V.", + "She received a loading dose of 400 mg/m2 cetuximab I.V. over 2 h (5 mg/min).", + "She did not develop any infusion reaction.", + "She was admitted to hospital 4 h after completing cetuximab infusion.", + "She had sudden headaches.", + "She had photophobia.", + "She had neck stiffness.", + "She had vomiting.", + "She had no fever.", + "Cerebrospinal fluid analysis showed a cloudy liquid.", + "CSF protein was 1.5 g/L.", + "CSF red blood cell count was 6/μL.", + "CSF leukocyte count was 4100/μL.", + "CSF glucose was 3.16 mM.", + "Blood glucose was 7.3 mM.", + "She was treated with empiric antibiotic therapy (ceftriaxone I.V.) for 7 days.", + "She recovered neurologically within 8 days.", + "Bacterial cultures remained negative.", + "Viral analysis including a viral encephalitis panel was performed by polymerase chain reaction.", + "Viral analysis remained negative.", + "Repeat CSF analysis was initially planned 8 days after admission.", + "The lumbar puncture failed.", + "The lumbar puncture was not repeated as the patient was well.", + "Symptoms resolution was reported by day 2.", + "Radiation therapy was started 3 weeks after hospital admission.", + "Cetuximab was reintroduced 28 days after hospital admission.", + "Cetuximab was reintroduced at a lower dose of 250 mg/m2.", + "Methylprednisolone 80 mg I.V. was added to premedication.", + "The infusion flow rate of cetuximab was decreased to 2 mg/min.", + "She tolerated cetuximab well.", + "No side effects were reported during other additional infusions up to 10 weeks.", + "At 18 months follow-up, the patient is well with no evidence of tumor recurrence.", + "The temporal association, clinical and laboratory findings strongly support the diagnosis of cetuximab-induced aseptic meningitis.", + "Most patients with aseptic meningitis are treated with antibiotics.", + "Most patients recover within 2 weeks.", + "Resolution occurs several days after drug discontinuation.", + "Diagnosis of aseptic meningitis is based on viral and bacterial CSF profiles remaining sterile.", + "Nonsteroidal anti-inflammatory drugs, antibiotics, intravenous immunoglobulins, antiepileptic drugs, and monoclonal antibodies are the most frequent cause of drug-induced meningitis.", + "The first occurrence of drug-induced aseptic meningitis related to cetuximab was reported in 2000 by Baselga et al.", + "Since 2000, 7 other cases of cetuximab-induced aseptic meningitis have been described.", + "Cetuximab was reintroduced successfully for three of the reported cases.", + "Cetuximab was reintroduced with appropriate premedication and a slower infusion rate.", + "Adverse reactions always occurred during the first administration.", + "There are no cases described in colorectal cancer.", + "Cetuximab is commonly dosed at 500 mg/m2 every 2 weeks in colorectal cancer." + ], + "summary": "We present the case of a middle-aged Caucasian patient, who presented with fever and headache within a few hours of starting cetuximab therapy and was diagnosed with cetuximab-induced aseptic meningitis after a complete workup.", + "summary_subclaims": [ + "The patient was middle-aged.", + "The patient was Caucasian.", + "The patient presented with fever.", + "The patient presented with headache.", + "The symptoms occurred within a few hours of starting cetuximab therapy.", + "The patient was diagnosed with cetuximab-induced aseptic meningitis.", + "The diagnosis was made after a complete workup." + ] + }, + { + "id": "multiclinsum_test_2953_en.txt", + "fulltext": "A 42-year-old Asian woman, gravida 0, para 0, underwent laparoscopic cystectomy for a suspected ovarian chocolate cyst at Kaiser Hospital in southern California, USA, in March 2014. Pathology revealed clear cell carcinoma. An optimal debulking operation was subsequently performed, and the patient was found to have FIGO stage II disease. She was administered adjuvant chemotherapy with paclitaxel and carboplatin for 7 cycles. However, an increasing serum CA-125 level and recurrent pelvic tumors were noted in January 2016. She underwent a secondary debulking operation, followed by administration of adjuvant chemotherapy using carboplatin and gemcitabine. However, secondary recurrence deep in the pelvic cavity close to the sigmoid colon, rectum, and bladder was found in September 2017. Her recurrence progressed despite the administration of salvage chemotherapy, including liposomal doxorubicin and topotecan. In February 2019, she presented to a medical center in Taiwan and underwent a third debulking surgery including resection of the sigmoid colon, rectum, and bladder, followed by small bowel bypass, T-colostomy and bilateral percutaneous nephrostomy. Tumor recurrence occurred, with two major masses observed in the pelvis and abdomen soon after surgery. Palliative treatment was suggested because she was refractory to cancer treatment. Immune cell therapy with unknown immunological cells was attempted at a clinic but was ineffective.\nShe presented to our hospital with a high CA125 level, a pelvic mass with resultant vaginal bleeding, and severe cachexia in April 2019. Based on her history, genetic analysis of more than 300 genes was performed (Foundation Medicine, FoundationOne CDx) and revealed a stable microsatellite status, low mutation burden, and two mutations in ARID1A . Immunohistochemical staining of PD-L1 was negative . After discussion, the patient and her family agreed to treatment with a checkpoint inhibitor combined with bevacizumab, with the understanding that the checkpoint inhibitor alone would not effectively treat EOC based on previous clinical trials. The patient was administered pembrolizumab (200 mg) combined with bevacizumab (15 mg/kg; 400 mg) every 3 weeks. Her serum CA-125 level dramatically decreased from 1236.6 to 639.2 U/mL after 1 cycle of treatment; her CA-125 level reached the normal range (35 U/mL) after 7 cycles . Computerized tomography (CT) scanning also showed significant regression of recurrent masses and a partial response at 3 months after beginning treatment. The patient’s disease achieved complete remission after 9 cycles . She recovered from cachexia to a normal body mass index , as evidenced by an increase in subcutaneous fat and muscle in axial view CT images, as shown in Fig. . There were no adverse effects, such as hypertension, pneumonitis, colitis, or hepatitis, except for small joint arthritis in both hands in later cycles. As of the time of preparation of this manuscript, the patient has remained disease-free.", + "fulltext_subclaims": [ + "The patient is a 42-year-old Asian woman.", + "She underwent laparoscopic cystectomy for a suspected ovarian chocolate cyst at Kaiser Hospital in southern California, USA, in March 2014.", + "Pathology revealed clear cell carcinoma.", + "An optimal debulking operation was performed.", + "The patient was found to have FIGO stage II disease.", + "She was administered adjuvant chemotherapy with paclitaxel and carboplatin for 7 cycles.", + "An increasing serum CA-125 level and recurrent pelvic tumors were noted in January 2016.", + "She underwent a secondary debulking operation.", + "She was administered adjuvant chemotherapy using carboplatin and gemcitabine.", + "Secondary recurrence deep in the pelvic cavity close to the sigmoid colon, rectum, and bladder was found in September 2017.", + "Her recurrence progressed despite the administration of salvage chemotherapy, including liposomal doxorubicin and topotecan.", + "In February 2019, she underwent a third debulking surgery including resection of the sigmoid colon, rectum, and bladder, followed by small bowel bypass, T-colostomy and bilateral percutaneous nephrostomy.", + "Tumor recurrence occurred, with two major masses observed in the pelvis and abdomen soon after surgery.", + "Palliative treatment was suggested because she was refractory to cancer treatment.", + "Immune cell therapy with unknown immunological cells was attempted at a clinic but was ineffective.", + "She presented to our hospital with a high CA125 level, a pelvic mass with resultant vaginal bleeding, and severe cachexia in April 2019.", + "Genetic analysis of more than 300 genes was performed (Foundation Medicine, FoundationOne CDx).", + "The genetic analysis revealed a stable microsatellite status.", + "The genetic analysis revealed a low mutation burden.", + "The genetic analysis revealed two mutations in ARID1A.", + "Immunohistochemical staining of PD-L1 was negative.", + "The patient and her family agreed to treatment with a checkpoint inhibitor combined with bevacizumab.", + "The patient was administered pembrolizumab (200 mg) combined with bevacizumab (15 mg/kg; 400 mg) every 3 weeks.", + "Her serum CA-125 level dramatically decreased from 1236.6 to 639.2 U/mL after 1 cycle of treatment.", + "Her CA-125 level reached the normal range (35 U/mL) after 7 cycles.", + "Computerized tomography (CT) scanning showed significant regression of recurrent masses and a partial response at 3 months after beginning treatment.", + "The patient’s disease achieved complete remission after 9 cycles.", + "She recovered from cachexia to a normal body mass index.", + "There were no adverse effects, such as hypertension, pneumonitis, colitis, or hepatitis, except for small joint arthritis in both hands in later cycles.", + "The patient has remained disease-free as of the time of preparation of this manuscript." + ], + "summary": "We present a patient with refractory OCCC in whom conventional chemotherapy failed. Cachexia was induced by the disseminating recurrent tumors. Tumor tissue staining and genomic analysis revealed PD-L1 negativity, a low tumor burden, stable microsatellite instability, and two mutations in ARID1A. The patient was administered pembrolizumab combined with bevacizumab triweekly. Her serum CA-125 level decreased dramatically after the first cycle. A computerized tomography scan showed marked regression of the recurrent masses after 3 cycles, and the patient reached complete remission after 9 cycles. She showed good recovery from cachexia. We observed no marked side effects except for mild polyarthritis of the small joints.", + "summary_subclaims": [ + "The patient had refractory ovarian clear cell carcinoma.", + "Conventional chemotherapy failed.", + "Cachexia was induced by the disseminating recurrent tumors.", + "Tumor tissue staining and genomic analysis revealed PD-L1 negativity.", + "Tumor tissue staining and genomic analysis revealed a low tumor burden.", + "Tumor tissue staining and genomic analysis revealed stable microsatellite instability.", + "Tumor tissue staining and genomic analysis revealed two mutations in ARID1A.", + "The patient was administered pembrolizumab combined with bevacizumab triweekly.", + "Her serum CA-125 level decreased dramatically after the first cycle.", + "A computerized tomography scan showed marked regression of the recurrent masses after 3 cycles.", + "The patient reached complete remission after 9 cycles.", + "The patient showed good recovery from cachexia.", + "We observed no marked side effects except for mild polyarthritis of the small joints." + ] + }, + { + "id": "multiclinsum_test_1143_en.txt", + "fulltext": "A 27-year-old Japanese man was brought to the emergency room with coma. He was diagnosed as having schizophrenia at the age of 13 and as having autism spectrum disorder at the age of 18. The medication at that time was 50 mg/day of atomoxetine, 5 mg/day of risperidone and 3 mg/day of guanfacine, although risperidone was decreased from 9 to 5 mg and guanfacine was increased from 2 to 3 mg 35 days before. He had been drinking over 4 L of water for the last few weeks. His impaired consciousness level was 3 points (E1V1M1) of the Glasgow coma scale (GCS). His vital signs were as follows: temperature, 39.1°C; blood pressure, 174/98 mmHg; heart rate, 95 beats/min; oxygen saturation, 92% (under 9 L of O2 supply). shows laboratory data in emergency room. He suffered from abnormal balance of electrolytes. As shown in , he had significant hyponatremia and hypochloremia with normal potassium concentration, and reduction of blood osmotic pressure. His inflammation markers were markedly elevated. In addition, he suffered from rhabdomyolysis. Indeed, his creatine kinase, myoglobin and urinary myoglobin levels were significantly high. As shown in , his head computed tomography (CT) revealed severe cerebral edema. In addition, significant fluid retention was observed throughout the body, namely, pleural effusion, pulmonary and intestinal edema . We evaluated the causes of hyponatremia in this patient. Since antidiuretic hormone (ADH) level was elevated to 0.8 pg/ml when sodium level was 109 mmol/L, we diagnosed him with syndrome of inappropriate secretion of ADH (SIADH). Based on these findings, we thought that he probably suffered from severe cerebral edema which was induced by hyponatremia associated with NMS and SIADH. In addition, rhabdomyolysis and NMS was diagnosed necessitating comprehensive therapy in intensive care unit (ICU).\nOn admission to ICU, he required mechanical ventilation and administration of 0.9% NaCl. Moreover, we started immediately administering 10% glyceol (600 ml/once a day, 5 days + 400 ml/once a day, 2 days + 200 ml/once a day, 2 days) for cerebral edema and continuous furosemide (3 days) for diuresis. In addition, he was treated with methylprednisolone (1,000 mg/once a day, 3 days) for cerebral edema and suspection of autoimmune encephalitis, and with dantrolene (40 mg/once a day, 1 day + 100 mg/once a day, 4 days + 60 mg/once a day, 2 days) for NMS. Eye openings and spontaneous limb movements were observed several times at day 2 (his sodium level, 115 mmol/L). His impaired consciousness was improved and he was able to speak sometimes at day 3 (his sodium level, 130 mmol/L). The patient was extubated at day 3 and his head CT revealed the improvement of severe cerebral edema at day 4 . Finally, we successfully treated severe cerebral edema and hyponatremia, which was induced and complicated with NMS, water intoxication, SIADH and rhabdomyolysis. shows a time course of his cerebral edema and shows his clinical time course in ICU. His adrenal and thyroid function was normal (adrenocorticotropic hormone, 61.7 pg/ml; cortisol, 13.0 μg/dl; thyroid stimulating hormone, 3.208 μIU/ml; free triiodothyronine, 2.89 pg/ml; free thyroxine, 1.03 ng/dl; respectively) after correction of hyponatremia. He was transferred from ICU to general ward at day 9 and was discharged 29 days after admission.\nAfter discharge, he was followed-up by the psychosomatic center of another hospital. He continued to receive the same psychosomatic treatment and did not have recurrence of malignant syndromes or water intoxication.", + "fulltext_subclaims": [ + "A 27-year-old Japanese man was brought to the emergency room with coma.", + "He was diagnosed as having schizophrenia at the age of 13.", + "He was diagnosed as having autism spectrum disorder at the age of 18.", + "The medication at that time was 50 mg/day of atomoxetine.", + "The medication at that time was 5 mg/day of risperidone.", + "The medication at that time was 3 mg/day of guanfacine.", + "Risperidone was decreased from 9 to 5 mg 35 days before.", + "Guanfacine was increased from 2 to 3 mg 35 days before.", + "He had been drinking over 4 L of water for the last few weeks.", + "His impaired consciousness level was 3 points (E1V1M1) of the Glasgow coma scale (GCS).", + "His temperature was 39.1°C.", + "His blood pressure was 174/98 mmHg.", + "His heart rate was 95 beats/min.", + "His oxygen saturation was 92% under 9 L of O2 supply.", + "He suffered from abnormal balance of electrolytes.", + "He had significant hyponatremia.", + "He had significant hypochloremia.", + "He had normal potassium concentration.", + "He had reduction of blood osmotic pressure.", + "His inflammation markers were markedly elevated.", + "He suffered from rhabdomyolysis.", + "His creatine kinase, myoglobin and urinary myoglobin levels were significantly high.", + "His head computed tomography (CT) revealed severe cerebral edema.", + "Significant fluid retention was observed throughout the body.", + "Antidiuretic hormone (ADH) level was elevated to 0.8 pg/ml when sodium level was 109 mmol/L.", + "He was diagnosed with syndrome of inappropriate secretion of ADH (SIADH).", + "He probably suffered from severe cerebral edema which was induced by hyponatremia associated with NMS and SIADH.", + "Rhabdomyolysis and NMS was diagnosed.", + "He required mechanical ventilation.", + "He received administration of 0.9% NaCl.", + "He was administered 10% glyceol for cerebral edema.", + "He received continuous furosemide for diuresis.", + "He was treated with methylprednisolone for cerebral edema.", + "He was treated with dantrolene for NMS.", + "Eye openings and spontaneous limb movements were observed several times at day 2.", + "His sodium level was 115 mmol/L at day 2.", + "His impaired consciousness was improved and he was able to speak sometimes at day 3.", + "His sodium level was 130 mmol/L at day 3.", + "He was extubated at day 3.", + "His head CT revealed the improvement of severe cerebral edema at day 4.", + "He was successfully treated for severe cerebral edema and hyponatremia.", + "He was transferred from ICU to general ward at day 9.", + "He was discharged 29 days after admission.", + "After discharge, he was followed-up by the psychosomatic center of another hospital.", + "He continued to receive the same psychosomatic treatment.", + "He did not have recurrence of malignant syndromes.", + "He did not have recurrence of water intoxication." + ], + "summary": "Herein we report a comatose case of NMS complicated with water intoxication, syndrome of SIADH and rhabdomyolysis. This patient had severe cerebral edema and hyponatremia that were improved rapidly by the correction of hyponatremia within a couple of days.", + "summary_subclaims": [ + "The patient was comatose.", + "The case involved neuroleptic malignant syndrome.", + "The case was complicated with water intoxication.", + "The case was complicated with syndrome of inappropriate antidiuretic hormone secretion.", + "The case was complicated with rhabdomyolysis.", + "The patient had severe cerebral edema.", + "The patient had hyponatremia.", + "Hyponatremia was improved rapidly by correction within a couple of days." + ] + }, + { + "id": "multiclinsum_test_2538_en.txt", + "fulltext": "We present a case of a 74-year-old man smoker patient with NSCLC with bone metastases (T2NXM1) and HCC (BCLC stage C). The patient had a related liver cirrhosis metabolic syndrome, good liver function (Child Pugh A5), and reported a diabetes mellitus type II in his past medical history. In July 2014 for chest and abdominal pain he performed a CT scan with evidence of lung and liver lesions, and bone metastasis. Lung biopsy performed on primary lung lesion showed pulmonary adenocarcinoma (TTF1 positive and p40 negative) and liver biopsy showed HCC (grade 2 Edmondson) . As the patient was not in good clinical conditions due to grade 2 asthenia, we decided to start with gemcitabine in monochemotherapy in August 2014. After 2 months of chemotherapy a further CT scan showed a disease progression in both the lung and the liver. We decided to initiate treatment with sorafenib with standard schedule (400 mg bid continuously).\nCT scan before therapy showed that the primary liver lesion measured 97 mm × 98.3 mm . The primary lung lesion measured 40.9 mm × 29.3 mm and the metastasis in the contralateral lung measured 27 mm × 25 mm . After 20 days we decided to reduce the dose of sorafenib to 400 mg per day for adverse events (hypertension grade 2 and mucositis grade 3). This dose was maintained until progression, without adverse events. CT scan after 2 months showed partial response in both lung lesions and stable disease in the liver and bone lesions. CT scan after 6 months of therapy showed partial response of the primary lung lesion and complete response of the lung metastasis . HCC was stable . After 13 months of therapy CT scan showed a disease progression in both the lung and the liver . Due to poor performance status of the patient we decided to treat patient with only best supportive care.\nThe pulmonary lesion underwent routine diagnostic molecular characterization for EGFR, KRAS, NRAS, PIK3CA, BRAF, ERBB2, ALK, DDR2, MAP2K1, RET mutations using Myriapod Lung Status (MassARRAY Sequenom). Results revealed an exon 11 point mutation on BRAF gene (G469V).\nThe same analysis was performed on the liver lesion, with no mutations in the different genes. Genomic DNA extraction from both lesions was performed starting from tumor sections composed of about 70 % of tumor cells.\nTaking into consideration our previous results obtained in HCC patients, in which we have demonstrated that specific polymorphisms of eNOS, VEGFA, VEGFC and HIF-1alpha seem to correlate with response to sorafenib [–], we performed the analysis of such polymorphisms on our patient. Results showed an homozygous status for eNOS VNTR (4bb) and HIF-1alpha rs12434438 GG. Both of these polymorphisms were associated with a worse prognosis in our previous studies [–].\nThe molecular determinations performed on the liver lesion (not part of routine molecular diagnostics) and the polymorphism analyses, both part of an ongoing research protocol on liver cancer approved by our Local Ethics Committee, were carried out after obtaining written consent from the patient.", + "fulltext_subclaims": [ + "The patient is a 74-year-old man.", + "The patient is a smoker.", + "The patient has non-small cell lung cancer (NSCLC) with bone metastases.", + "The patient has hepatocellular carcinoma (HCC).", + "The patient has liver cirrhosis.", + "The patient has metabolic syndrome.", + "The patient has type II diabetes mellitus in his past medical history.", + "The patient had chest and abdominal pain in July 2014.", + "A CT scan in July 2014 showed lung and liver lesions.", + "A CT scan in July 2014 showed bone metastasis.", + "A lung biopsy showed pulmonary adenocarcinoma.", + "The lung biopsy showed TTF1 positivity.", + "The lung biopsy showed p40 negativity.", + "A liver biopsy showed HCC.", + "The liver biopsy showed grade 2 Edmondson HCC.", + "The patient had grade 2 asthenia.", + "The patient started gemcitabine monochemotherapy in August 2014.", + "A CT scan after 2 months showed disease progression in both the lung and the liver.", + "The patient started sorafenib with a standard schedule of 400 mg bid continuously.", + "The primary liver lesion measured 97 mm × 98.3 mm before therapy.", + "The primary lung lesion measured 40.9 mm × 29.3 mm before therapy.", + "The contralateral lung metastasis measured 27 mm × 25 mm before therapy.", + "After 20 days, the dose of sorafenib was reduced to 400 mg per day.", + "The dose reduction was due to hypertension grade 2 and mucositis grade 3.", + "The reduced dose was maintained until progression.", + "A CT scan after 2 months showed partial response in both lung lesions.", + "A CT scan after 2 months showed stable disease in the liver and bone lesions.", + "A CT scan after 6 months showed partial response of the primary lung lesion.", + "A CT scan after 6 months showed complete response of the lung metastasis.", + "HCC was stable after 6 months of therapy.", + "A CT scan after 13 months showed disease progression in both the lung and the liver.", + "The patient received best supportive care due to poor performance status.", + "The pulmonary lesion underwent molecular characterization for EGFR, KRAS, NRAS, PIK3CA, BRAF, ERBB2, ALK, DDR2, MAP2K1, and RET mutations.", + "The molecular characterization used Myriapod Lung Status (MassARRAY Sequenom).", + "The results revealed an exon 11 point mutation on the BRAF gene (G469V).", + "The same analysis was performed on the liver lesion.", + "The liver lesion showed no mutations in the different genes.", + "Genomic DNA extraction was performed from tumor sections composed of about 70% tumor cells.", + "The analysis of eNOS, VEGFA, VEGFC, and HIF-1alpha polymorphisms was performed.", + "The patient had an homozygous status for eNOS VNTR (4bb).", + "The patient had HIF-1alpha rs12434438 GG.", + "Both polymorphisms were associated with worse prognosis in previous studies.", + "The molecular determinations on the liver lesion were not part of routine molecular diagnostics.", + "The polymorphism analyses were part of an ongoing research protocol on liver cancer.", + "The research protocol was approved by the Local Ethics Committee.", + "Written consent was obtained from the patient." + ], + "summary": "Here we report a case of a patient with two synchronous tumors, HCC and NSCLC, with metastases in the contralateral lung and bone. The patient was treated with gemcitabine as first line, with a resulting progressive disease after two months, and then with sorafenib at standard dosage in the second line setting. After 6 months of treatment CT scan showed a partial response in the primary lesion of the lung, complete response of the metastasis in the contralateral lung, and stability of HCC. The patient had progression in the lung, liver and bone after 13 months of therapy. A molecular characterization of NSCLC and HCC lesions was performed, revealing a BRAF exon 11 mutation (G469V) only in NSCLC. We hypothesize that the response observed in NSCLC lesions could be due to the presence of BRAF mutation, and that this alteration could be responsible in determining sorafenib sensitivity.", + "summary_subclaims": [ + "The patient had two synchronous tumors, HCC and NSCLC.", + "The patient had metastases in the contralateral lung and bone.", + "The patient was treated with gemcitabine as first line.", + "Progressive disease was observed after two months of gemcitabine.", + "Sorafenib was used at standard dosage in the second line setting.", + "After 6 months of sorafenib, CT scan showed a partial response in the primary lesion of the lung.", + "After 6 months of sorafenib, CT scan showed a complete response of the metastasis in the contralateral lung.", + "After 6 months of sorafenib, CT scan showed stability of HCC.", + "The patient had progression in the lung, liver, and bone after 13 months of therapy.", + "Molecular characterization revealed a BRAF exon 11 mutation (G469V) only in NSCLC.", + "The response observed in NSCLC lesions could be due to the presence of BRAF mutation.", + "The BRAF mutation could be responsible for determining sorafenib sensitivity." + ] + }, + { + "id": "multiclinsum_test_1543_en.txt", + "fulltext": "A 56-year-old female military officer was referred to the Colorectal Surgical Department for mid-rectal cancer 8 cm from the anal verge. The patient had no past medical history. Her physical examination and routine laboratory studies were unremarkable. Her carcinoembryonic antigen level was 5.93 ng/ml, and an abdomino-pelvic computed tomography (CT) scan showed no intra-abdominal metastasis. Pelvic magnetic resonance imaging showed a clinical T2N0 tumor. The patient underwent laparoscopic low anterior resection and diverting loop ileostomy. The operation time was 310 min. The pathologic results showed that the adenocarcinoma had infiltrated the proper muscle layer (T2) with no lymph node metastasis (0/17). On postoperative day 3, the patient complained of vomiting and abdominal pain, and a follow-up abdomino-pelvic CT scan showed an ileo-ileal type intussusception . Two days of surgical observation were unsuccessful, and her nausea and abdominal pain continued. The patient then underwent exploratory laparotomy. On exploration, intussusception was found 40 cm proximal to the loop ileostomy site. The proximal ileum (P, intussusceptum) had invaginated into the distal segment (D, intussuscipiens), and segmental resection of the ileum was carried out . There was no pathological leading point on the resected ileum . The patient recovered uneventfully and was discharged on postoperative day 14 after the second operation. The patient has remained in good health for two years.", + "fulltext_subclaims": [ + "The patient was referred to the Colorectal Surgical Department for mid-rectal cancer 8 cm from the anal verge.", + "The patient had no past medical history.", + "The patient's carcinoembryonic antigen level was 5.93 ng/ml.", + "An abdomino-pelvic CT scan showed no intra-abdominal metastasis.", + "Pelvic magnetic resonance imaging showed a clinical T2N0 tumor.", + "The patient underwent laparoscopic low anterior resection and diverting loop ileostomy.", + "The operation time was 310 min.", + "The pathologic results showed that the adenocarcinoma had infiltrated the proper muscle layer (T2).", + "The pathologic results showed no lymph node metastasis (0/17).", + "On postoperative day 3, the patient complained of vomiting and abdominal pain.", + "A follow-up abdomino-pelvic CT scan showed an ileo-ileal type intussusception.", + "Two days of surgical observation were unsuccessful.", + "The patient then underwent exploratory laparotomy.", + "On exploration, intussusception was found 40 cm proximal to the loop ileostomy site.", + "The proximal ileum had invaginated into the distal segment.", + "Segmental resection of the ileum was carried out.", + "There was no pathological leading point on the resected ileum.", + "The patient was discharged on postoperative day 14 after the second operation.", + "The patient has remained in good health for two years." + ], + "summary": "A 56-year-old female military officer was referred to the Colorectal Surgical Department for mid-rectal cancer, 8 cm from the anal verge. The patient underwent laparoscopic low anterior resection and diverting loop ileostomy. On postoperative day 3, the patient complained of vomiting and abdominal pain, and a follow-up abdomino-pelvic computed tomography scan showed an ileo-ileal type intussusception. After two days of surgical observation, her clinical symptoms were not resolved. The patient underwent exploratory laparotomy. On exploration, intussusception was found 40 cm proximal to the loop ileostomy site. Segmental resection of the ileum was carried out, and there was no pathological leading point on the resected ileum. The patient was discharged on postoperative day 14 after the second operation and has remained in good health for two years.", + "summary_subclaims": [ + "The patient was referred to the Colorectal Surgical Department for mid-rectal cancer.", + "The mid-rectal cancer was 8 cm from the anal verge.", + "The patient underwent laparoscopic low anterior resection.", + "The patient underwent diverting loop ileostomy.", + "On postoperative day 3, the patient complained of vomiting.", + "On postoperative day 3, the patient complained of abdominal pain.", + "A follow-up abdomino-pelvic computed tomography scan showed an ileo-ileal type intussusception.", + "After two days of surgical observation, her clinical symptoms were not resolved.", + "The patient underwent exploratory laparotomy.", + "Intussusception was found 40 cm proximal to the loop ileostomy site.", + "Segmental resection of the ileum was carried out.", + "There was no pathological leading point on the resected ileum.", + "The patient was discharged on postoperative day 14 after the second operation.", + "The patient has remained in good health for two years." + ] + }, + { + "id": "multiclinsum_test_1018_en.txt", + "fulltext": "A previously healthy 12-year-old girl presented with a 2-year history of chronic progressive bilateral knee pain, worsening in the preceding 6 months. Her symptoms were episodic and variable in duration and severity, with difficulty participating in sports. She had a 2.5 kg weight loss over 2 months and low BMI of 14 kg/m2. She denied any gastrointestinal symptoms, oral ulcers, skin changes, or ocular symptoms. She had not tried any specific treatments or interventions. She is of South Asian background and the product of a non-consanguineous relationship. There is no relevant family history of CRMO, autoinflammatory disease, or IBD. Examination showed fullness and tenderness in both medial femoral condyles. Her abdominal and perianal examinations were benign.\nInitial investigations showed a normocytic anemia (Hb 112 g/L, MCV 79 fL), raised transaminases (ALT 84, AST 81, ALP 227, GGT 146 U/L), and raised inflammatory markers (ESR 94 mm/hr., CRP 15 mg/L). X-rays of the hips, femur, and knees showed distal femoral metaphyseal lytic lesions with surrounding sclerosis, and MRI of the lower limbs revealed multifocal distal femoral bone marrow abnormalities with regional edema pattern, cortical thickening, and periostitis . A whole-body MRI revealed additional bone marrow edema pattern involving bilateral medial clavicular heads and right acromion.\nThe patient was treated with a single dose of intravenous zoledronic acid (0.0125 mg/kg) with significant clinical improvement and improved mobilization, but demonstrated persistently abnormal liver enzymes (AST 71, ALT 67, GGT 124 U/L), anemia (Hb 106 g/L), and raised inflammatory markers (ESR 82 mm/hr) and gamma globulins (IgG 30.1 g/L, IgM 3.3 g/L). Conjugated bilirubin was < 0.2umol/L, albumin was 42 g/L, and INR was 1.0. The patient remained asymptomatic without abdominal pain or bowel alterations, jaundice, or pale stools.\nFurther workup with pediatric gastroenterology was concerning for Type 1 Autoimmune Hepatitis (AIH) with Anti-Smooth muscle > 1:640, ANA negative, Anti-LKM negative, and ANCA negative. Abdominal ultrasound showed mildly heterogeneous liver echotexture but a normal biliary tree; magnetic resonance cholangiopancreatography was normal. Transient elastography showed increased liver stiffness (8.8 kPa, IQR/median of 7%). Liver biopsy showed features of both small-duct PSC and AIH, with interface hepatitis with plasma cells, concentric fibrosis of bile ducts, grade 3–4 hepatitis and stage 3–4 fibrosis. Other diagnoses including hepatitis B/C and tuberculosis, Wilson disease and celiac disease were excluded.\nAlthough the patient was asymptomatic, given the strong association between PSC and IBD, the patient’s fecal calprotectin was measured. This was elevated at 615 μg/g, and so she underwent gastroscopy and colonoscopy. This showed chronic mildly active colitis (non-granulomatous) from cecum to rectum with normal terminal ileum, and normal upper endoscopy, leading to a diagnosis of ulcerative colitis.\nThe patient’s liver and gastrointestinal disease was treated with oral prednisone (35 mg oral daily), azathioprine (75 mg oral once daily), and ursodeoxycholic acid (250 mg oral daily) with sufficient adherence. No reported adverse effects were reported. There was normalization of liver biochemistry and liver stiffness (5.5 kPa with IQR/median 19%) within 6 months. The patient’s musculoskeletal symptoms remain inactive 11 months since initial therapy with zoledronic acid.", + "fulltext_subclaims": [ + "The patient is a 12-year-old girl.", + "She had a 2-year history of chronic progressive bilateral knee pain.", + "The knee pain had worsened in the preceding 6 months.", + "She had a 2.5 kg weight loss over 2 months.", + "Her BMI was 14 kg/m2.", + "She denied any gastrointestinal symptoms.", + "She denied any ocular symptoms.", + "She had not tried any specific treatments or interventions.", + "Examination showed fullness and tenderness in both medial femoral condyles.", + "Initial investigations showed a normocytic anemia with Hb 112 g/L.", + "Initial investigations showed raised transaminases (ALT 84, AST 81, ALP 227, GGT 146 U/L).", + "X-rays showed distal femoral metaphyseal lytic lesions with surrounding sclerosis.", + "MRI showed multifocal distal femoral bone marrow abnormalities with regional edema pattern.", + "A whole-body MRI showed additional bone marrow edema pattern involving bilateral medial clavicular heads.", + "The patient was treated with a single dose of intravenous zoledronic acid (0.0125 mg/kg).", + "The patient demonstrated persistently abnormal liver enzymes (AST 71, ALT 67, GGT 124 U/L).", + "The patient remained asymptomatic without abdominal pain.", + "Further workup showed Anti-Smooth muscle antibody > 1:640.", + "Abdominal ultrasound showed mildly heterogeneous liver echotexture.", + "Liver biopsy showed features of both small-duct PSC and AIH.", + "Fecal calprotectin was elevated at 615 μg/g.", + "Gastroscopy and colonoscopy showed chronic mildly active colitis from cecum to rectum.", + "The patient was diagnosed with ulcerative colitis.", + "The patient was treated with oral prednisone, azathioprine, and ursodeoxycholic acid.", + "Liver biochemistry and liver stiffness normalized within 6 months.", + "The patient’s musculoskeletal symptoms remain inactive 11 months since initial therapy." + ], + "summary": "We present a unique case of a pediatric patient with an initial diagnosis of CRMO, with subsequent diagnosis of autoimmune hepatitis and PSC overlap, and eventually IBD.", + "summary_subclaims": [ + "The patient was initially diagnosed with CRMO.", + "The patient was subsequently diagnosed with autoimmune hepatitis and PSC overlap.", + "The patient was eventually diagnosed with IBD." + ] + }, + { + "id": "multiclinsum_test_950_en.txt", + "fulltext": "This is a case of a 68-year-old male smoker (50 pack-year history). The occupation of the patient is a farmer. No family history of cancers or lung cancer. He was admitted to hospital due to cough, sputum and dyspnea. He had a 4-year history of COPD and a 3-year history of well-controlled chronic gastritis. He had no other medical conditions such as high blood pressure, diabetes, obesity or autoimmune disease and denied drinking alcohol. Physical examination revealed a barrel-chest.Wet rales and wheezing could be heard in the right upper lung. Laboratory data showed WBC 11.90/109/L (reference, 4–10/109/L), Neu 8.75/109/L (reference, 2.5–7.5/109/L), Lym 0.94/109/L (reference, 1.5–3.3/109/L), CRP 149.77 mg/L (reference, ≤ 10 mg/L). Blood gas analysis PO2 77.10 mmHg (reference, 80-100 mmHg). Chest computerized tomographic (CT) scan revealed signs of emphysema, irregular mass-like consolidation with cavity shadows in the right upper lobe, and thickening of local interlobular septa . Bronchoscopy and alveolar lavage showed no abnormality. Combined with clinical manifestations, laboratory examination and imaging data, he was diagnosed as community acquired pneumonia (CAP). He was treated with intravenous ceftizoxime (1 g/Q12h/9d) for anti-infection, intravenous methylprednisolone (40 mg/qd/5d), atomized salbutamol for antispasmosis, relief of bronchoscpasm, cough and expectorant treatment, and was discharged with improvement. Pulmonary function testing showed a decreased FEV1/FVC ratio (53.47), an FEV1 of 1.08 L (45% normal), and reduced diffusing capacity of 23%. After discharge, he was treated with LABA/LAMA and recovered well. He did not return to the hospital for follow-up.\nAbout 7 months after discharge, the patient returned to the hospital for cough and dyspnea. Physical examination of the left upper lung breathing sound was low. Laboratory data showed a cytokeratin 19 fragment of 2.42 ng/ml (reference, < 3.3 ng/ml) and neuron-specific enolase 85.87 ng/ml (reference, 0–16.3 ng/ml). Contrast-enhanced chest CT showed resolution of the right upper lung lesion and residual scarring . Irregular mass in the bronchial opening area of the upper lobe of the left lung and fusion with enlarged lymph nodes in the left hilum and adjacent mediastinum: Central lung cancer of the left lung with left pulmonary obstructive inflammation, lymph node metastasis in the mediastinum and left hilum, and arteriovenous invasion of the left upper lung were considered to be highly possible . At the same time, we compared the images of the first hospitalization at the same layers .\nPositron emission tomography/CT did not detect an increase in standard uptake value except the lung. Fibrobronchoscopy revealed infiltrating growth of new organisms in the bronchial mucosa of the left upper lobe of the lung covered with white membrane-like neoplasm . We compared images of the same site at the first admission . Biopsy diagnosed SCLC . This patient PD-L1 Tumor Proportion Score was 52%. The diagnosis was ES-SCLC.\nThe patient intravenously received cisplatin (75 mg/m2) and etoposide (80 mg/m2 on days 1–3) and durvalumab (humanized monoclonal PD-L1 inhibitor, 1500 mg) every 3 weeks for four cycles. 2 months after treatment, the patient achieved partial remission (PR) in imaging assessment , and the patient refused prophylactic cranial irradiation and chest radiotherapy. Durvalumab (1500 mg) was administered once every four weeks, and the disease progressed after four times of maintenance treatment . The patient refused chemotherapy again, immunotherapy and radiotherapy, anlotinib and analgesic drugs orally only, and went home to hospice care. He succumbed to his disease approximately 9 months after his diagnosis.", + "fulltext_subclaims": [ + "The patient is a 68-year-old male.", + "The patient is a smoker with a 50 pack-year history.", + "The patient's occupation is a farmer.", + "There is no family history of cancers or lung cancer.", + "The patient was admitted to hospital due to cough, sputum, and dyspnea.", + "The patient had a 4-year history of COPD.", + "The patient had a 3-year history of well-controlled chronic gastritis.", + "The patient had no other medical conditions such as high blood pressure, diabetes, obesity, or autoimmune disease.", + "The patient denied drinking alcohol.", + "Physical examination revealed a barrel-chest.", + "Wet rales and wheezing could be heard in the right upper lung.", + "Laboratory data showed WBC 11.90/109/L.", + "Chest CT scan revealed signs of emphysema.", + "Chest CT scan showed irregular mass-like consolidation with cavity shadows in the right upper lobe.", + "Chest CT scan showed thickening of local interlobular septa.", + "Bronchoscopy and alveolar lavage showed no abnormality.", + "The patient was diagnosed as community acquired pneumonia.", + "The patient was treated with intravenous ceftizoxime (1 g/Q12h/9d).", + "The patient was treated with intravenous methylprednisolone (40 mg/qd/5d).", + "The patient was discharged with improvement.", + "Pulmonary function testing showed a decreased FEV1/FVC ratio (53.47).", + "Pulmonary function testing showed an FEV1 of 1.08 L (45% normal).", + "Pulmonary function testing showed reduced diffusing capacity of 23%.", + "The patient was treated with LABA/LAMA after discharge.", + "The patient did not return to the hospital for follow-up.", + "About 7 months after discharge, the patient returned to the hospital for cough and dyspnea.", + "Physical examination of the left upper lung breathing sound was low.", + "Laboratory data showed a cytokeratin 19 fragment of 2.42 ng/ml.", + "Contrast-enhanced chest CT showed resolution of the right upper lung lesion and residual scarring.", + "Contrast-enhanced chest CT showed an irregular mass in the bronchial opening area of the upper lobe of the left lung.", + "Contrast-enhanced chest CT showed fusion with enlarged lymph nodes in the left hilum and adjacent mediastinum.", + "Fibrobronchoscopy revealed infiltrating growth of new organisms in the bronchial mucosa of the left upper lobe of the lung covered with white membrane-like neoplasm.", + "Biopsy diagnosed SCLC.", + "The patient PD-L1 Tumor Proportion Score was 52%.", + "The diagnosis was ES-SCLC.", + "The patient intravenously received cisplatin (75 mg/m2) and etoposide (80 mg/m2 on days 1–3) and durvalumab (1500 mg) every 3 weeks for four cycles.", + "2 months after treatment, the patient achieved partial remission (PR) in imaging assessment.", + "The patient refused prophylactic cranial irradiation and chest radiotherapy.", + "Durvalumab (1500 mg) was administered once every four weeks.", + "The disease progressed after four times of maintenance treatment.", + "The patient refused chemotherapy again, immunotherapy and radiotherapy.", + "The patient took anlotinib and analgesic drugs orally only.", + "The patient went home to hospice care.", + "He succumbed to his disease approximately 9 months after his diagnosis." + ], + "summary": "Herein, we report the case of an 68-year-old male presented to the respiratory department with cough, sputum, and dyspnea. He was diagnosed as community acquired pneumonia and treated with intravenous anti-infection. Previous pulmonary function was definitively diagnosed as COPD. About 7 months after discharge, the patient returned to the hospital for cough and dyspnea. After diagnosis of the tumor, cisplatin, etoposide and durvalumab were administered. Finally the patient died of respiratory failure approximately 9 months after his diagnosis.", + "summary_subclaims": [ + "The patient was a 68-year-old male.", + "The patient presented with cough, sputum, and dyspnea.", + "The patient was diagnosed as community acquired pneumonia.", + "The patient was treated with intravenous anti-infection.", + "Previous pulmonary function was definitively diagnosed as COPD.", + "The patient returned to the hospital for cough and dyspnea.", + "After diagnosis of the tumor, cisplatin, etoposide and durvalumab were administered.", + "The patient died of respiratory failure.", + "The patient died approximately 9 months after his diagnosis." + ] + }, + { + "id": "multiclinsum_test_1624_en.txt", + "fulltext": "A 71-year-old man presented to our emergency center with a history of diffused abdominal pain with intermittent hematochezia for 38 h. The patient denied other GI or genitourinary complaints, had an unremarkable medical history, and did not undergo prior abdominal surgery. On physical examination, the abdomen appeared tender with extensive rebound tenderness. Unfortunately, his groin areas were ignored to check due to lack of specific complaints. The blood investigation revealed a decreased hemoglobin level (9.6 g/dL). A contrast-enhanced CT scan indicated a lower GI bleeding resulting from a ruptured mass (5.2 × 4.1 × 3.0 cm3) located in small intestine. Meanwhile, CT imaging showed a minimal mass (2.0 × 1.5 × 0.5 cm3) in his right groin but failed to mention in the emergent report .\nThe patient was immediately managed with an emergent laparotomy in light of the hemodynamic instability. During the surgery, the primary tumor was found arising from the third jejunal segment (220 cm distant from the duodenal-jejunal flexure), with disseminated, multi-focal progression of tumor seeding recorded. A palliative resection of primary tumor and seeding tumors (> 2 mm) in abdomen was achieved (R1 resection), followed by a side-to-side bowel anastomosis. The patient was discharged at the 11th post-operative day without any complications. The histopathologic report of primary tumor suggested a GIST of spindle cell nature, with high mitotic count (25/50 HPF) and significant tumor necrosis (Additional file : Fig. S1). The immunohistochemical (IHC) staining evaluation indicated severe positivity for CD117, DOG-1 and SDHB, mild positivity for actin and desmin, but negative for CD34 and S-100. The Ki-67 index was 20%. The molecular analysis reported a mutation rate of 18.22% for the c-KIT, mainly located on A502_T503dup exon 9. The tumor was hence categorized as high-risk jejunal GIST.\nThe patient received imatinib chemotherapy (400 mg/day) postoperatively for three months until a complaint of persistent pain in the right groin. On physical examination, a painful, irreducible, non-pulsatile mass (2.0 × 2.0 × 1.0 cm3) was felt in right groin, with negative finding in contralateral side. He was referred to the hernia unit of our department. Additional CT imaging was performed to exclude abdominal recurrence. Afterward, a definitive herniorrhaphy with Lichtenstein’s approach was accomplished , with the mass along with sac removed before placing a self-gripping polyester mesh (TEM1208GR, Parietex ProGrip™, US). The intraoperative diagnosis was right indirect inguinal hernia, Gilbert II classification . The patient was discharged at the second post-operative day. The final pathological report of resected specimen in his groin indicated a metastasized GIST in inguinal hernia. The tumor was spindle cells morphology, with high mitotic count (> 40/50 HPF) and strongly positive immunostains of CD117, DOG-1, Bcl-2 and CD99. The Ki-67 index was 30%, with partial positivity for SDHB .\nThe patient continued the imatinib chemotherapy as mentioned ahead, with planed outpatient clinic visits scheduled. At the last follow-up visit on February 14th, 2020, he was survived and capable of daily work, without a recurrent inguinal hernia observed.", + "fulltext_subclaims": [ + "A 71-year-old man presented to our emergency center with a history of diffused abdominal pain with intermittent hematochezia for 38 h.", + "The patient denied other GI or genitourinary complaints.", + "The patient had an unremarkable medical history.", + "The patient did not undergo prior abdominal surgery.", + "On physical examination, the abdomen appeared tender with extensive rebound tenderness.", + "The groin areas were ignored to check due to lack of specific complaints.", + "The blood investigation revealed a decreased hemoglobin level (9.6 g/dL).", + "A contrast-enhanced CT scan indicated a lower GI bleeding resulting from a ruptured mass (5.2 × 4.1 × 3.0 cm3) located in small intestine.", + "CT imaging showed a minimal mass (2.0 × 1.5 × 0.5 cm3) in his right groin.", + "The emergent CT report failed to mention the right groin mass.", + "The patient was immediately managed with an emergent laparotomy in light of the hemodynamic instability.", + "During the surgery, the primary tumor was found arising from the third jejunal segment (220 cm distant from the duodenal-jejunal flexure).", + "Disseminated, multi-focal progression of tumor seeding was recorded.", + "A palliative resection of primary tumor and seeding tumors (> 2 mm) in abdomen was achieved.", + "The resection was classified as R1.", + "A side-to-side bowel anastomosis was performed.", + "The patient was discharged at the 11th post-operative day without any complications.", + "The histopathologic report of primary tumor suggested a GIST of spindle cell nature.", + "The tumor had a high mitotic count (25/50 HPF).", + "The tumor had significant tumor necrosis.", + "The immunohistochemical staining indicated severe positivity for CD117.", + "The immunohistochemical staining indicated severe positivity for DOG-1.", + "The immunohistochemical staining indicated severe positivity for SDHB.", + "The immunohistochemical staining indicated mild positivity for actin.", + "The immunohistochemical staining indicated mild positivity for desmin.", + "The immunohistochemical staining was negative for CD34.", + "The immunohistochemical staining was negative for S-100.", + "The Ki-67 index was 20%.", + "The molecular analysis reported a mutation rate of 18.22% for the c-KIT.", + "The c-KIT mutation was mainly located on A502_T503dup exon 9.", + "The tumor was categorized as high-risk jejunal GIST.", + "The patient received imatinib chemotherapy (400 mg/day) postoperatively for three months.", + "The patient had a complaint of persistent pain in the right groin.", + "A painful, irreducible, non-pulsatile mass (2.0 × 2.0 × 1.0 cm3) was felt in right groin.", + "The contralateral side had negative findings.", + "The patient was referred to the hernia unit of our department.", + "Additional CT imaging was performed to exclude abdominal recurrence.", + "A definitive herniorrhaphy with Lichtenstein’s approach was accomplished.", + "The mass along with sac was removed before placing a self-gripping polyester mesh.", + "The intraoperative diagnosis was right indirect inguinal hernia, Gilbert II classification.", + "The patient was discharged at the second post-operative day.", + "The final pathological report of resected specimen in his groin indicated a metastasized GIST in inguinal hernia.", + "The tumor had spindle cells morphology.", + "The tumor had a high mitotic count (> 40/50 HPF).", + "The tumor was strongly positive for CD117.", + "The tumor was strongly positive for DOG-1.", + "The tumor was strongly positive for Bcl-2.", + "The tumor was strongly positive for CD99.", + "The Ki-67 index was 30%.", + "The tumor had partial positivity for SDHB.", + "The patient continued the imatinib chemotherapy.", + "At the last follow-up visit on February 14th, 2020, he was survived.", + "At the last follow-up visit on February 14th, 2020, he was capable of daily work.", + "At the last follow-up visit on February 14th, 2020, no recurrent inguinal hernia was observed." + ], + "summary": "We herein reported a metastasized case presented as GI hemorrhage complicated with indirect hernia, and underwent tumor cytoreduction, herniorrhaphy and chemotherapy for jejunal GIST. The case was described consecutively based on the process of surgical management, with a good follow-up result. A literature review by searching similar case reports from two national medical databases was performed to summarize clinical features of such unusual presentation of GIST, which included hernia characteristics, short- and long-term outcomes of this disease. It showed GIST presenting as groin hernia was rarely reported and all available 11 cases suggested a primary tumor and required both tumor resection and hernia repair. The long-term results indicated 64.3% overall survival at 5 years after the incidental diagnosis.", + "summary_subclaims": [ + "The case was a metastasized case presented as GI hemorrhage complicated with indirect hernia.", + "The patient underwent tumor cytoreduction, herniorrhaphy, and chemotherapy for jejunal GIST.", + "The case was described consecutively based on the process of surgical management.", + "The follow-up result was good.", + "A literature review was performed by searching similar case reports from two national medical databases.", + "The literature review aimed to summarize clinical features of the unusual presentation of GIST.", + "The clinical features included hernia characteristics, short- and long-term outcomes of the disease.", + "GIST presenting as groin hernia was rarely reported.", + "All available 11 cases suggested a primary tumor.", + "All available 11 cases required both tumor resection and hernia repair.", + "The long-term results indicated 64.3% overall survival at 5 years after the incidental diagnosis." + ] + }, + { + "id": "multiclinsum_test_896_en.txt", + "fulltext": "A 60-year-old male with a mild factor VIII deficiency presented to the hematology clinic at our hospital with a 1-week history of asymptomatic gross hematuria. He had suffered a hemorrhagic gastric ulcer at the age of 48 and was diagnosed with mild hemophilia A (his factor VIII levels were 6 % of normal) at that time. He had suffered a cerebral hemorrhage at the age of 59. For several years beginning at the age of 50, the patient had experienced mild hematuria, and he had experienced one episode of intramuscular and subcutaneous hemorrhage; both conditions were managed with recombinant factor VIII products.\nA physical examination revealed no abnormal signs. Laboratory tests revealed that the patient’s activated partial thromboplastin time (aPTT) was prolonged to 74.6 s (normal range, 28.5–40.9 s), but his prothrombin time-international normalized ratio, platelet count, serum creatinine level, and prostate-specific antigen level were unremarkable. The patient’s urinalysis results were normal, except for the gross hematuria, and urine cytology revealed no cancer cells. The patient was treated with a third-generation recombinant factor VIII product (Advate). However, he had persistent hematuria, followed by clot retention. Thus, he was referred to the Department of Urology. Computed tomography demonstrated that his bladder was filled with a blood clot , but his prostate and upper urinary tract were apparently normal.\nHe was admitted to our hospital and received the following therapy: clot evacuation by vesicoclysis, continuous bladder irrigation with normal saline, and intravesical instillation of aluminum hydroxide/magnesium hydroxide (Maalox) concurrent with the administration of Advate, which failed to resolve the hemorrhage. Consequently, the patient had repeated transfusions of packed red cells. Although the patient also underwent transurethral coagulation of the bladder mucosa under anesthesia, the bleeding presented with oozing throughout the mucosa and was not controlled. Subsequently, the patient developed pyelonephritis in his left kidney with a severe reduction (<50 mL) in his bladder capacity. Conservative management for 2 months failed to resolve the patient’s symptoms, so he was offered a cystectomy with ileal conduit and consented to it after a detailed discussion.\nThe quality of intraoperative clotting seemed to be normal with the use of sufficient Advate to raise the levels of factor VIII to 100 % (3000 U, IV bolus) and the transfusion of 3 U of fresh-frozen plasma. His aPTT was 54 s during surgery. The cystectomy was performed safely without severe bleeding events. A 15-cm length of ileal segment at 15 cm from the ileocecal valve was used for the ileal conduit. The technique of side-to-side stapled anastomosis was used for the ileoileal anastomosis, and the Bricker anastomosis technique was used for ureteroileal anastomosis. The total operating time was 220 min and the estimated blood loss was 800 mL.\nThe resected specimen revealed multiple erosions and ulcers in the bladder mucosa, and sclerosis of the bladder wall. Histological examinations demonstrated inflammatory cell infiltration and fibrous changes in the bladder wall without malignant figures. The cause of the hematuria was unclear.\nPostoperatively, Advate (3000 U, q12 h) was administered to maintain 100 % levels of factor VIII for 2 days with no bleeding complications. After removal of the ureteral catheters on postoperative day 13, the patient had urinary leakage from the ureteroileal anastomosis, which induced a pelvic abscess followed by septic shock and acute respiratory distress syndrome. Blood cultures were positive for Candida tropicalis. Several antibiotics and surgical drainage of the abscess were needed.\nAt 4 months after the cystectomy, the patient had blood in his stool requiring a transfusion of packed red cells. No bleeding site was demonstrated in the colon by colonoscopy and 99mTechnetium-human serum albumin-diethylenetriaminepenta-acetic acid scintigraphy demonstrated that the extravasation of radioactive isotope was detected at terminal ileum, cecum, ascending and transverse colon but not at the oral side of terminal ileum . These findings were suspected to be bleeding from the ileoileal anastomosis. The patient was given Advate (2000–4000 U) three times per week for 6 months, and the blood in his stool resolved. His condition recovered gradually and he was discharged at 8 months after admission.\nAfter discharge, he had mild gastrointestinal bleeding and mild hematuria several times a year; however, this was controlled by Advate. The patient had been doing well, other than the bleeding tendency, until he suffered a malignant lymphoma at the age of 66 and was transferred to another clinic for treatment.", + "fulltext_subclaims": [ + "The patient is a 60-year-old male.", + "He has a mild factor VIII deficiency.", + "He presented with a 1-week history of asymptomatic gross hematuria.", + "He had a hemorrhagic gastric ulcer at the age of 48.", + "He was diagnosed with mild hemophilia A at the age of 48.", + "His factor VIII levels were 6 % of normal.", + "He had a cerebral hemorrhage at the age of 59.", + "He had experienced mild hematuria for several years beginning at the age of 50.", + "He had one episode of intramuscular and subcutaneous hemorrhage.", + "Both conditions were managed with recombinant factor VIII products.", + "A physical examination revealed no abnormal signs.", + "The patient’s activated partial thromboplastin time (aPTT) was prolonged to 74.6 s.", + "The normal range for aPTT is 28.5–40.9 s.", + "His prothrombin time-international normalized ratio was unremarkable.", + "His platelet count was unremarkable.", + "His serum creatinine level was unremarkable.", + "His prostate-specific antigen level was unremarkable.", + "Urinalysis results were normal, except for the gross hematuria.", + "Urine cytology revealed no cancer cells.", + "The patient was treated with a third-generation recombinant factor VIII product (Advate).", + "He had persistent hematuria.", + "He had clot retention.", + "Computed tomography demonstrated that his bladder was filled with a blood clot.", + "His prostate and upper urinary tract were apparently normal.", + "He was admitted to the hospital.", + "He received clot evacuation by vesicoclysis.", + "He received continuous bladder irrigation with normal saline.", + "He received intravesical instillation of aluminum hydroxide/magnesium hydroxide (Maalox).", + "This was concurrent with the administration of Advate.", + "This failed to resolve the hemorrhage.", + "He had repeated transfusions of packed red cells.", + "He underwent transurethral coagulation of the bladder mucosa under anesthesia.", + "The bleeding presented with oozing throughout the mucosa.", + "The bleeding was not controlled.", + "He developed pyelonephritis in his left kidney.", + "He had a severe reduction (<50 mL) in his bladder capacity.", + "Conservative management for 2 months failed to resolve the patient’s symptoms.", + "He was offered a cystectomy with ileal conduit.", + "He consented to it after a detailed discussion.", + "The quality of intraoperative clotting seemed to be normal.", + "Sufficient Advate was used to raise the levels of factor VIII to 100 %.", + "3000 U of Advate was administered as an IV bolus.", + "3 U of fresh-frozen plasma were transfused.", + "His aPTT was 54 s during surgery.", + "The cystectomy was performed safely without severe bleeding events.", + "A 15-cm length of ileal segment at 15 cm from the ileocecal valve was used for the ileal conduit.", + "The technique of side-to-side stapled anastomosis was used for the ileoileal anastomosis.", + "The Bricker anastomosis technique was used for ureteroileal anastomosis.", + "The total operating time was 220 min.", + "The estimated blood loss was 800 mL.", + "The resected specimen revealed multiple erosions and ulcers in the bladder mucosa.", + "Histological examinations demonstrated inflammatory cell infiltration and fibrous changes in the bladder wall.", + "There were no malignant figures.", + "The cause of the hematuria was unclear.", + "Postoperatively, Advate (3000 U, q12 h) was administered.", + "This was to maintain 100 % levels of factor VIII for 2 days.", + "There were no bleeding complications.", + "After removal of the ureteral catheters on postoperative day 13, the patient had urinary leakage from the ureteroileal anastomosis.", + "This induced a pelvic abscess.", + "This was followed by septic shock.", + "This was followed by acute respiratory distress syndrome.", + "Blood cultures were positive for Candida tropicalis.", + "Several antibiotics and surgical drainage of the abscess were needed.", + "At 4 months after the cystectomy, the patient had blood in his stool.", + "This required a transfusion of packed red cells.", + "No bleeding site was demonstrated in the colon by colonoscopy.", + "99mTechnetium-human serum albumin-diethylenetriaminepenta-acetic acid scintigraphy demonstrated that the extravasation of radioactive isotope was detected at terminal ileum, cecum, ascending and transverse colon.", + "The extravasation was not detected at the oral side of terminal ileum.", + "These findings were suspected to be bleeding from the ileoileal anastomosis.", + "The patient was given Advate (2000–4000 U) three times per week for 6 months.", + "The blood in his stool resolved.", + "His condition recovered gradually.", + "He was discharged at 8 months after admission.", + "After discharge, he had mild gastrointestinal bleeding and mild hematuria several times a year.", + "This was controlled by Advate.", + "The patient had been doing well, other than the bleeding tendency.", + "He suffered a malignant lymphoma at the age of 66.", + "He was transferred to another clinic for treatment." + ], + "summary": "A 60-year-old male with hemophilia A presented with persistent gross hematuria of unknown cause. He was treated with recombinant factor VIII products, followed by several conservative therapies as follows: clot evacuation by vesicoclysis, continuous bladder irrigation with normal saline, and intravesical instillation of aluminum hydroxide/magnesium hydroxide (Maalox); however, these failed to resolve the hemorrhaging. The patient was offered and consented to cystectomy with an ileal conduit. Intraoperative clotting was normal with the infusion of adequate recombinant factor VIII products and transfusion of fresh-frozen plasma, and the procedure was performed safely. After surgery, the patient had blood in his stool several times. No bleeding site was demonstrated in the colon by colonoscopy and (99m)Technetium-human serum albumin-diethylenetriaminepenta-acetic acid scintigraphy demonstrated that the extravasation of radioactive isotope was detected at the anal side of terminal ileum but not at the oral side. These findings were suspected to be bleeding from the ileoileal anastomosis. However, the bleeding was managed with recombinant factor VIII products.", + "summary_subclaims": [ + "The patient is a 60-year-old male with hemophilia A.", + "The patient had persistent gross hematuria of unknown cause.", + "The patient was treated with recombinant factor VIII products.", + "The patient received clot evacuation by vesicoclysis.", + "The patient had continuous bladder irrigation with normal saline.", + "The patient had intravesical instillation of aluminum hydroxide/magnesium hydroxide (Maalox).", + "These treatments failed to resolve the hemorrhaging.", + "The patient was offered cystectomy with an ileal conduit.", + "The patient consented to cystectomy with an ileal conduit.", + "Intraoperative clotting was normal with the infusion of adequate recombinant factor VIII products.", + "Intraoperative clotting was normal with transfusion of fresh-frozen plasma.", + "The procedure was performed safely.", + "After surgery, the patient had blood in his stool several times.", + "No bleeding site was demonstrated in the colon by colonoscopy.", + "(99m)Technetium-human serum albumin-diethylenetriaminepenta-acetic acid scintigraphy demonstrated extravasation of radioactive isotope at the anal side of terminal ileum.", + "(99m)Technetium-human serum albumin-diethylenetriaminepenta-acetic acid scintigraphy did not demonstrate extravasation at the oral side.", + "These findings were suspected to be bleeding from the ileoileal anastomosis.", + "The bleeding was managed with recombinant factor VIII products." + ] + }, + { + "id": "multiclinsum_test_2273_en.txt", + "fulltext": "A 44-year-old woman with bipolar disorder was referred to our outpatient clinic 2 months after her first manic episode. She developed bipolar disorder with depressive episodes when she was 42 years old. Her first depressive episode was ameliorated with 3 months’ treatment with sertraline. She had no previous episodes of hypomania or mixed states, and no history of thyroid disease. When she presented at our clinic, she had been treated with quetiapine for 1 month, but still had elevated mood, irritability, and mood-congruent delusions. According to the Diagnostic and Statistical Manual of Mental Disorders, 5th edition, we diagnosed her as having bipolar I disorder, and added 200 mg of valproate on 100 mg of quetiapine. Valproate was later increased to 400 mg, after which, her manic symptoms ameliorated.\nDespite her mood being well controlled, she developed severe fatigue 30 days after starting valproate. She had no depression-related symptoms other than fatigue, and no findings suggesting sedation with valproate such as somnolence or impaired attention. Her blood concentration of valproate was 24.2 μg/mL, which was not at the toxic level (normal range 50–100 μg/mL). She had never had a similar reaction to previously used psychotropics. A physical examination and laboratory test found no abnormalities except for low values of free thyroxine 0.50 ng/dL (F-T4; normal range 0.8–1.5 ng/dL) and free triiodothyronine 1.85 pg/mL (F-T3; normal range 2.0–3.8 pg/mL). Although F-T4 was decreased, thyroid-stimulating hormone 2.97 μU/mL (TSH; normal range 0.34–3.8 μU/mL) was within the normal range, suggesting central hypothyroidism. Since other fatigue-causing medical conditions and medications were ruled out by systematic evaluations, we considered that the severe fatigue was associated with hypothyroidism. Thyroid autoantibodies were negative, and gadolinium-enhanced magnetic resonance imaging of the pituitary gland showed no evidence of a pituitary lesion. Considering that her F-T4 levels progressively decreased with increasing doses of valproate (F-T4 0.70 ng/dL under 200 mg and F-T4 0.50 ng/dL under 400 mg), we suspected that her hypothyroidism was caused by valproate. Therefore, we stopped valproate 33 days after its introduction. Her severe fatigue then improved, completely disappearing in about 20 days. A laboratory test 35 days after stopping valproate confirmed that her thyroid function had normalized (TSH 2.17 μU/mL, F-T3 2.99 pg/mL, F-T4 1.10 ng/dL). For the next 12 months, she had no recurrence of mood episodes, hypothyroidism, or fatigue under maintenance treatment with risperidone and carbamazepine.", + "fulltext_subclaims": [ + "The patient is a 44-year-old woman with bipolar disorder.", + "She was referred to the outpatient clinic 2 months after her first manic episode.", + "She developed bipolar disorder with depressive episodes at age 42.", + "Her first depressive episode was ameliorated with 3 months of treatment with sertraline.", + "She had no previous episodes of hypomania or mixed states.", + "She had no history of thyroid disease.", + "At the time of presentation, she had been treated with quetiapine for 1 month.", + "She still had elevated mood, irritability, and mood-congruent delusions.", + "She was diagnosed with bipolar I disorder according to the Diagnostic and Statistical Manual of Mental Disorders, 5th edition.", + "Valproate 200 mg was added to 100 mg of quetiapine.", + "Valproate was later increased to 400 mg.", + "Her manic symptoms ameliorated after valproate was increased to 400 mg.", + "She developed severe fatigue 30 days after starting valproate.", + "Her blood concentration of valproate was 24.2 μg/mL.", + "The valproate concentration was not at the toxic level.", + "A physical examination found no abnormalities except for low free thyroxine and free triiodothyronine.", + "Thyroid-stimulating hormone was within the normal range.", + "The decreased free thyroxine suggested central hypothyroidism.", + "Thyroid autoantibodies were negative.", + "Gadolinium-enhanced magnetic resonance imaging of the pituitary gland showed no evidence of a pituitary lesion.", + "Her free thyroxine levels progressively decreased with increasing doses of valproate.", + "Valproate was stopped 33 days after its introduction.", + "Her severe fatigue improved after stopping valproate.", + "Her fatigue completely disappeared in about 20 days.", + "A laboratory test 35 days after stopping valproate confirmed that her thyroid function had normalized.", + "For the next 12 months, she had no recurrence of mood episodes, hypothyroidism, or fatigue.", + "She was under maintenance treatment with risperidone and carbamazepine." + ], + "summary": "A 44-year-old woman with bipolar I disorder complained of severe fatigue after starting valproate. She showed a hormonal pattern of central hypothyroidism. Thyroid autoantibodies were negative, and no pituitary abnormality was seen on magnetic resonance imaging. After stopping valproate, her severe fatigue rapidly improved with normalizing thyroid function.", + "summary_subclaims": [ + "The patient is a 44-year-old woman with bipolar I disorder.", + "She complained of severe fatigue after starting valproate.", + "She showed a hormonal pattern of central hypothyroidism.", + "Thyroid autoantibodies were negative.", + "No pituitary abnormality was seen on magnetic resonance imaging.", + "After stopping valproate, her severe fatigue rapidly improved.", + "Her thyroid function normalized after stopping valproate." + ] + }, + { + "id": "multiclinsum_test_424_en.txt", + "fulltext": "An asymptomatic 23-month-old boy, weighed 10.5 kg, was incidentally diagnosed with congenital heart disease while presenting to the hospital for another illness. Transthoracic echocardiography (TTE) revealed one 18-mm ASD located in the inferior portion of the atrial septum that resulted in an overriding inferior vena cava (IVC), and the right inferior pulmonary vein (RIPV) partially returned to the right atrium (RA) near the orifice of the IVC. TTE also showed a complete left-to-right atrial shunt, no tricuspid regurgitation, and right ventricular dilation (with a diameter of 15 mm). Cardiac catheterization confirmed a normal anatomy of coronary arteries and a pulmonary to systemic flow ratio (Qp/Qs) of 3.2:1.\nThe patient was placed in a supine position with the right side of the body elevated to 30°. Two arms were placed along the body and the patient was under general anesthesia with a single-lumen endotracheal tube. One 14F-arterial cannula (Medtronic, Inc., Minneapolis, Minn, USA) used as a superior vena cava (SVC) cannula was inserted through the right internal jugular vein with Seldinger technique. Four trocars were set up on the right chest wall, included the following: one 12 mm trocar in the 5th intercostal space (ICS) at the anterior axillary line as the main working port, one 5 mm trocar in the 4th ICS at the mid-axillary line as the secondary working port, one 5 mm trocar in the 5th ICS at the mid-axillary line as the camera port and one 5 mm trocar in the 6th ICS at the mid-axillary line for right heart sucker.\nThe ventilation volume was reduced to 50%–75% compared with conventional practice. The anesthetist continuously monitored the oxygen saturation with a finger pulse oximeter and maintained it ≥95% throughout the operation. With this ventilation technique, the lungs were collapsed enough for the surgeon to open and hang up the pericardium. The large right lobe of the thymus covered the majority of the pericardium surrounding the aorta and the SVC. Therefore, we dissected this lobe from the pericardium (while preserving the tissue and supplying vessels) and hung it on to the anterior chest wall with a suture. The pericardium was opened parallel to and at 1.5 cm away from the anterior chest wall. The inferior edge of the pericardium was hung up to the diaphragm (the caudal end) and through the trocar (the cephalic end) by some sutures to expose the surgical field (Video 1). At this stage, respiratory ventilation was continued as usual.\nTo expose the ascending aorta, the top of the right atrial appendage was sutured and pulled down through a trocar. A 2–0, 17 mm braided suture (ETHIBOND EXCEL® Polyester Suture, ETHICON, JOHNSON & JOHNSON, Shanghai, China) was used to make a purse-string suture on the anterior wall of the ascending aorta, right beneath the semicircular fat plica (A) (Video 2). A 12F-arterial cannula (Medtronic, Inc., Minneapolis, Minn, USA) was placed superiorly through right anterior chest wall in the 4th ICS, 1 cm away from the right border of the sternum. This process was performed from the outside combined with endoscopic visualization from inside to avoid injury to the internal thoracic artery and ensure that the cannula was best directed to the purse-string suture . We placed a piece of a 10 F rubber catheter (Red Rubber Latex All-Purpose Intermittent Catheters, Medline, USA) about 1.3 to 1.5 cm away from the tip of the arterial cannula to work as a brake. Subsequently, a surgical scalpel blade No.11 (Aesculap, Inc.) was used to open the ascending aorta inside the purse-string suture. The arterial cannula was then introduced via this ostium into the ascending aorta until the brake on the cannula reached the aortic wall (B, C) (Video 3). The arterial cannula was fixed and the cardiopulmonary bypass (CPB) was started.\nA CO2-pump line connecting to the camera port was used to fill the pericardial and pleural spaces with CO2. Initially, CO2 was pumped with a rate of 0.5 l/min, and then the pump rate was adjusted to maintain the partial pressure of CO2 in arterial blood ranging from 35 to 40 mmHg. Arterial line pressure was maintained >50 mmHg during the operation.\nA loop was placed around the SVC to act as a tourniquet but not snaring. The patient was placed in the Trendelenburg position. The tourniquet on the SVC was tightened after opening the RA (Video 4). The blood returning to the RA from the IVC was drained by a stiff sucker, which also acted as an atrial retractor to expose the lesion. The edges of RA were hung to the pericardium by stitches to expose structures inside the RA. After determining the location, size of the ASD, as well as the anatomical correlation between the IVC and the RIPV, an artificial patch was used to close the ASD and form a canal to drain blood from the RIPV to the LA through the ASD (A, B) (Video 5). Right before completing the ASD closure, the lung was inflated to remove air from the left atrium. The RA was closed in a two-layer fashion using continuous stitches. The extracorporeal circulation was stopped and the surgery was finished uneventfully. The operative and cardiopulmonary bypass times were 259 and 133 min, respectively. The patient stayed in the intensive care unit for 18 h and was discharged on postoperative-day 7 without neurological complication or blood transfusion. TTE prior to discharge revealed a completely closed ASD, patent IVC, and RIPV ostia. Both the patient and his family were extremely satisfied with the cosmetic results of surgical scars (C).", + "fulltext_subclaims": [ + "The patient was an asymptomatic 23-month-old boy.", + "The patient weighed 10.5 kg.", + "The patient was incidentally diagnosed with congenital heart disease.", + "Transthoracic echocardiography revealed one 18-mm ASD located in the inferior portion of the atrial septum.", + "The ASD resulted in an overriding inferior vena cava.", + "The right inferior pulmonary vein partially returned to the right atrium near the orifice of the IVC.", + "TTE showed a complete left-to-right atrial shunt.", + "TTE showed no tricuspid regurgitation.", + "TTE showed right ventricular dilation with a diameter of 15 mm.", + "Cardiac catheterization confirmed a normal anatomy of coronary arteries.", + "Cardiac catheterization showed a pulmonary to systemic flow ratio (Qp/Qs) of 3.2:1.", + "The patient was placed in a supine position with the right side of the body elevated to 30°.", + "Two arms were placed along the body.", + "The patient was under general anesthesia with a single-lumen endotracheal tube.", + "One 14F-arterial cannula was used as a superior vena cava cannula.", + "The cannula was inserted through the right internal jugular vein with Seldinger technique.", + "Four trocars were set up on the right chest wall.", + "One 12 mm trocar was placed in the 5th intercostal space at the anterior axillary line as the main working port.", + "One 5 mm trocar was placed in the 4th ICS at the mid-axillary line as the secondary working port.", + "One 5 mm trocar was placed in the 5th ICS at the mid-axillary line as the camera port.", + "One 5 mm trocar was placed in the 6th ICS at the mid-axillary line for right heart sucker.", + "The ventilation volume was reduced to 50%–75% compared with conventional practice.", + "The anesthetist continuously monitored oxygen saturation with a finger pulse oximeter.", + "Oxygen saturation was maintained ≥95% throughout the operation.", + "The large right lobe of the thymus covered the majority of the pericardium surrounding the aorta and the SVC.", + "The large right lobe of the thymus was dissected from the pericardium.", + "The pericardium was opened parallel to and at 1.5 cm away from the anterior chest wall.", + "The inferior edge of the pericardium was hung up to the diaphragm and through the trocar.", + "A 2–0, 17 mm braided suture was used to make a purse-string suture on the anterior wall of the ascending aorta.", + "A 12F-arterial cannula was placed superiorly through the right anterior chest wall in the 4th ICS, 1 cm away from the right border of the sternum.", + "A piece of a 10 F rubber catheter was placed 1.3 to 1.5 cm away from the tip of the arterial cannula.", + "A surgical scalpel blade No.11 was used to open the ascending aorta inside the purse-string suture.", + "The arterial cannula was introduced via the ostium into the ascending aorta until the brake on the cannula reached the aortic wall.", + "A CO2-pump line connecting to the camera port was used to fill the pericardial and pleural spaces with CO2.", + "Initially, CO2 was pumped at a rate of 0.5 l/min.", + "The pump rate was adjusted to maintain the partial pressure of CO2 in arterial blood ranging from 35 to 40 mmHg.", + "Arterial line pressure was maintained >50 mmHg during the operation.", + "A loop was placed around the SVC to act as a tourniquet.", + "The patient was placed in the Trendelenburg position.", + "The tourniquet on the SVC was tightened after opening the RA.", + "The blood returning to the RA from the IVC was drained by a stiff sucker.", + "The edges of RA were hung to the pericardium by stitches.", + "An artificial patch was used to close the ASD and form a canal to drain blood from the RIPV to the LA through the ASD.", + "Right before completing the ASD closure, the lung was inflated to remove air from the left atrium.", + "The RA was closed in a two-layer fashion using continuous stitches.", + "The extracorporeal circulation was stopped and the surgery was finished uneventfully.", + "The operative time was 259 minutes.", + "The cardiopulmonary bypass time was 133 minutes.", + "The patient stayed in the intensive care unit for 18 hours.", + "The patient was discharged on postoperative-day 7.", + "There were no neurological complications.", + "There was no blood transfusion.", + "TTE prior to discharge revealed a completely closed ASD.", + "TTE prior to discharge showed patent IVC and RIPV ostia.", + "The patient and his family were extremely satisfied with the cosmetic results of surgical scars." + ], + "summary": "A 23-month-old boy, weighing 10.5 kg, with the diagnosis of sinus venosus ASD underwent successful repair by TES. We performed this surgery through 4 small trocars (one 12 mm trocar and three 5 mm trocars), without robotic assistance. In this case, we inserted the arterial cannula directly into the ascending aorta instead of the femoral artery (FA). The defects were repaired on the beating heart with CO2 insufflation.", + "summary_subclaims": [ + "The patient is a 23-month-old boy.", + "The patient weighs 10.5 kg.", + "The patient had the diagnosis of sinus venosus ASD.", + "The patient underwent successful repair by TES.", + "The surgery was performed through 4 small trocars.", + "One of the trocars was 12 mm.", + "Three of the trocars were 5 mm.", + "The surgery was performed without robotic assistance.", + "The arterial cannula was inserted directly into the ascending aorta.", + "The arterial cannula was not inserted into the femoral artery.", + "The defects were repaired on the beating heart.", + "CO2 insufflation was used during the repair." + ] + }, + { + "id": "multiclinsum_test_3085_en.txt", + "fulltext": "We report a case of 52-year-old white woman living in southwest Pennsylvania with a medical history significant for well-controlled hypertension (HTN), chronic obstructive pulmonary disease (COPD) without oxygen supplementation, and chronic back pain following multiple surgical interventions, currently managed with a spinal pain pump, presenting to an outside facility with exertional dyspnea. The patient reported subjective fever, chills, generalized fatigue, and polyarthralgia. She also reported persistent dizziness and occasional pre-syncope. Notably, she denied palpitations, chest pain, or skin rash, and she did not recall recent tick bites, but mentioned her dog’s diagnosis of Lyme disease following deer tick infestation a few months prior. Her vital signs revealed tachypnea and hypoxemia necessitating the initiation of 2 L of oxygen via nasal cannula.\n\nClinical Course\nAn electrocardiogram (EKG) displayed T-wave flattening in the anterolateral pre-cordial leads. Initial investigations included a chest X-ray, indicating pulmonary edema and inter-stitial infiltrates. Laboratory analysis revealed a significantly elevated B-type natriuretic peptide (BNP) of around 2800 pg/mL, along with mildly elevated troponins (128 ng/L). Consequently, the patient received ceftriaxone and doxycycline for presumed pneumonia, as well as intravenous furosemide therapy for acute heart failure exacerbation. Additionally, a 48-hour heparin infusion was initiated due to concerns regarding underlying acute coronary syndrome (NSTEMI). Subsequently, she was transferred to our hospital for further management.\n\nUpon arrival, her condition had stabilized, with the resolution of supplemental oxygen requirement and improvement in exertional dyspnea following diuretic therapy. However, she exhibited gradually worsening sinus bradycardia, with a heart rate in the 50s and significant hypotension (systolic blood pressure consistently below 90 mmHg). Telemetry monitoring and EKGs throughout the hospitalization revealed absence of AV block. Importantly, she continued to deny chest pain, shortness of breath, orthopnea, and paroxysmal nocturnal dyspnea. She did not show signs of end-organ dysfunction evidenced by normal mental status, lactate levels, urine output, renal, and liver functions. Her thyroid-stimulating hormone and 8 a.m. cortisol profiles were also normal (0.039 uIU/ml and 17.1 ug/dL, respectively). The respiratory viral panel result was unremarkable. Point-of-care ultrasound (POCUS) of the heart revealed a hypokinetic anterior left ventricular (LV) wall and mildly reduced ejection fraction by visual estimation, while the inferior vena cava (IVC) parameters were within the normal range and showed respiratory variation. Of note, her prior EKGs and echocardiograms were normal. Lyme serologies were ordered a few days after presentation due to the unclear etiology of new heart failure and in the setting of this persistent bradycardia.\n\nDue to persistent hypotension, reaching a nadir of 76/50 mmHg (MAP of 59), she was transferred to the Cardiovascular Intensive Care Unit (CVICU) for monitoring and potential pressor support. Lyme IgM and IgG titers followed by Western blot returned positive, leading to the continuation of ceftriaxone therapy for Lyme carditis. Formal echocardiography demonstrated mildly depressed LV systolic function with an ejection fraction of 50% and akinetic anteroseptal, anterolateral, and anterior LV walls. A coronary computed tomography angiogram (CTA) ruled out an ischemic etiology and coronary artery disease, revealing a coronary calcium score of 0. Over the following days, the patient’s condition gradually improved, with stabilization of blood pressure and heart rate, leading to her discharge on an extended course of intravenous ceftriaxone therapy (28 days) for the treatment of Lyme cardiac disease, manifested as myocarditis and cardiomyopathy. Cardiac MRI or endomyocardial biopsy were not pursued given the patient’s remarkably good clinical response to treatment. She was discharged on 14-day Holter monitor, showing absence of AV block.", + "fulltext_subclaims": [ + "The patient is a 52-year-old white woman.", + "She lives in southwest Pennsylvania.", + "She has a medical history of well-controlled hypertension.", + "She has chronic obstructive pulmonary disease without oxygen supplementation.", + "She has chronic back pain following multiple surgical interventions.", + "She is currently managed with a spinal pain pump.", + "She presented with exertional dyspnea.", + "She reported subjective fever.", + "She reported chills.", + "She reported generalized fatigue.", + "She reported polyarthralgia.", + "She reported persistent dizziness.", + "She reported occasional pre-syncope.", + "She denied palpitations.", + "She denied chest pain.", + "She denied skin rash.", + "She did not recall recent tick bites.", + "Her dog had a diagnosis of Lyme disease.", + "Her dog’s Lyme disease was due to deer tick infestation.", + "Her vital signs revealed tachypnea.", + "Her vital signs revealed hypoxemia.", + "She was started on 2 L of oxygen via nasal cannula.", + "An electrocardiogram showed T-wave flattening in the anterolateral precordial leads.", + "A chest X-ray showed pulmonary edema.", + "A chest X-ray showed interstitial infiltrates.", + "BNP was significantly elevated at around 2800 pg/mL.", + "Troponins were mildly elevated at 128 ng/L.", + "She received ceftriaxone and doxycycline for presumed pneumonia.", + "She received intravenous furosemide therapy for acute heart failure exacerbation.", + "A 48-hour heparin infusion was initiated due to concerns regarding underlying acute coronary syndrome.", + "She was transferred to another hospital for further management.", + "Upon arrival, her condition had stabilized.", + "She exhibited sinus bradycardia with a heart rate in the 50s.", + "She had significant hypotension with systolic blood pressure consistently below 90 mmHg.", + "Telemetry monitoring showed absence of AV block.", + "She continued to deny chest pain.", + "She continued to deny shortness of breath.", + "She continued to deny orthopnea.", + "She continued to deny paroxysmal nocturnal dyspnea.", + "She did not show signs of end-organ dysfunction.", + "Her mental status was normal.", + "Her lactate levels were normal.", + "Her urine output was normal.", + "Her renal function was normal.", + "Her liver function was normal.", + "Her thyroid-stimulating hormone was 0.039 uIU/ml.", + "Her 8 a.m. cortisol was 17.1 ug/dL.", + "The respiratory viral panel was unremarkable.", + "POCUS showed a hypokinetic anterior left ventricular wall.", + "POCUS showed mildly reduced ejection fraction by visual estimation.", + "The inferior vena cava parameters were within the normal range.", + "The inferior vena cava showed respiratory variation.", + "Her prior EKGs were normal.", + "Her prior echocardiograms were normal.", + "Lyme serologies were ordered a few days after presentation.", + "She was transferred to the Cardiovascular Intensive Care Unit.", + "Lyme IgM and IgG titers were positive.", + "Western blot was positive.", + "Ceftriaxone therapy was continued for Lyme carditis.", + "Formal echocardiography showed mildly depressed LV systolic function.", + "Formal echocardiography showed an ejection fraction of 50%.", + "Formal echocardiography showed akinetic anteroseptal, anterolateral, and anterior LV walls.", + "A coronary CTA ruled out an ischemic etiology.", + "A coronary CTA ruled out coronary artery disease.", + "The coronary calcium score was 0.", + "She was discharged on an extended course of intravenous ceftriaxone therapy.", + "The course of intravenous ceftriaxone therapy was 28 days.", + "The treatment was for Lyme cardiac disease.", + "The treatment was for myocarditis.", + "The treatment was for cardiomyopathy.", + "Cardiac MRI was not pursued.", + "Endomyocardial biopsy was not pursued.", + "She was discharged on a 14-day Holter monitor.", + "The Holter monitor showed absence of AV block." + ], + "summary": "We report a case of a 52-year-old woman with past medical history significant for hypertension, chronic obstructive pulmonary disease, and chronic back pain who presented with new-onset heart failure in the setting of Lyme carditis. She presented with exertional dyspnea requiring supplemental oxygen, subjective fever, chills, fatigue, and arthralgia of 2-week duration. Her vital signs were consistent with hypotension and persistent bradycardia. An EKG displayed T-wave flattening in the anterior pre-cordial leads. Further work-up was suggestive of bilateral pulmonary edema and interstitial infiltrates, which required antibiotics and diuretics. Echocardiography demonstrated new-onset mildly depressed LV systolic dysfunction. Interestingly, coronary CTA revealed coronary arteries with no evidence of stenosis or plaque. She was found to have positive Lyme IgM and lgG antibodies. A diagnosis of Lyme myocarditis was considered and her antibiotic course was extended following multidisciplinary consensus.", + "summary_subclaims": [ + "The patient is a 52-year-old woman.", + "The patient has a past medical history significant for hypertension.", + "The patient has a past medical history significant for chronic obstructive pulmonary disease.", + "The patient has a past medical history significant for chronic back pain.", + "The patient presented with new-onset heart failure.", + "The heart failure was in the setting of Lyme carditis.", + "The patient had exertional dyspnea requiring supplemental oxygen.", + "The patient had subjective fever.", + "The patient had chills.", + "The patient had fatigue.", + "The patient had arthralgia of 2-week duration.", + "The patient's vital signs were consistent with hypotension.", + "The patient's vital signs were consistent with persistent bradycardia.", + "An EKG displayed T-wave flattening in the anterior pre-cordial leads.", + "Further work-up was suggestive of bilateral pulmonary edema.", + "Further work-up was suggestive of interstitial infiltrates.", + "The patient required antibiotics.", + "The patient required diuretics.", + "Echocardiography demonstrated new-onset mildly depressed LV systolic dysfunction.", + "Coronary CTA revealed coronary arteries with no evidence of stenosis.", + "Coronary CTA revealed coronary arteries with no evidence of plaque.", + "The patient was found to have positive Lyme IgM antibodies.", + "The patient was found to have positive Lyme IgG antibodies.", + "A diagnosis of Lyme myocarditis was considered.", + "The antibiotic course was extended following multidisciplinary consensus." + ] + }, + { + "id": "multiclinsum_test_3176_en.txt", + "fulltext": "A 69-year-old man was admitted to the internal medicine department for the exploration of a progressive deterioration of his general condition associated with inflammatory-like low back pain for several weeks. He also reported a progressive weight loss of 15 kg over the last 3 months. He is a former diplomat with a profession requiring frequent travel abroad. He lived in sub-Saharan Africa for 20 years in rural areas. His medical history included a HIV infection controlled with a tritherapy (emtricitabine, rilpivirine, tenofovir alafenamide). Among the complications of HIV, he suffered from severe osteoporotic fractures in the vertebrae and sternum, which were treated with oral bisphosphonates with good compliance. He was an active smoker with more than 50 pack-years, and he also had obliterative arteriosclerosis of the lower limbs, which was treated with a femoro-femoral bypass in 2016.\n\nThe initial clinical examination showed camptocormia with invalidating lumbar pains sometimes causing insomnia and preventing walking. There was no fever, no breath sound, no anomaly in the examination of the tegument, no adenopathy, or organomegaly. He had a moderate inflammatory biological syndrome with a CRP of 42 mg/L (normal < 5 mg/L) associated with a moderate inflammatory anaemia and a discrete neutrophil increase (8.73 G/L, normal 1.5–7.5 G/L) without lymphopenia. There was cholestasis without cytolysis with gamma glutamyl transpeptidase and alkaline phosphatase at 183 IU/L (normal 12–64 IU/L) and 245 IU/L (normal 40–150 IU/L). The HIV viral load was undetectable and the CD4+ T lymphocyte count was 474/μL. A thoraco-abdomino-pelvic scan revealed an abscessed L3–L4 spondylodiscitis associated with known vertebral fractures. An MRI confirmed this diagnosis of spondylodiscitis with left paravertebral abscess without epidural extension. The peripheral infectious samples with blood cultures were all negative. A transthoracic echocardiography did not allow visualisation of vegetations without formally excluding an infammatory endocarditis. To exclude this diagnosis, a positron emission tomography – computed tomography (PET-CT) with cardiac preparation was performed due to the patient’s refusal of a transesophageal echocardiography. This examination revealed a L3–L4 hypermetabolism (SUV L3–L4 8.1 vs. hepatic SUV 2.77), but also an intense fixation at the femoral-femoral crossover bridge (SUV crossover 4.14 vs. hepatic SUV 2.77). The absence of valvular fixation allowed the exclusion of associated infammatory endocarditis. A discolumbo-vertebral biopsy was performed with a negative bacterial culture and a negative universal PCR (16S RNA). Unfortunately, the histology could not be performed due to insufficient material. The search for Mycobacterium tuberculosis in PCR and culture was negative on the discolumbo-vertebral biopsy material.\nIn the presence of an endovascular infection associated with a culture-negative spondylodiscitis, serology for C. burnetii was requested. The result was in favour of a chronic Q fever (phase I, immunoglobulin G [IgG] 4093 with threshold > 800). The specific PCR for C. burnetii requested on the material of the disco-vertebral biopsy was positive while the blood PCR for C. burnetii was negative.\nThe diagnosis of chronic Q fever with an abscessed L3-L4 spondylodiscitis and a femoro-femoral bypass infection was retained.\nAfter a medical-surgical discussion, the choice of a long-term treatment with hydroxychloroquine 600 mg and doxycycline 200 mg daily was initiated. The clinical evolution was favorable with a recovery of walking after a stay in the rehabilitation department. After two weeks of treatment, the biological inflammatory syndrome was completely negative. The IgG C. burnetii serology of phase 1 had decreased from a titre at 3 months and stabilised at this titre at the 6-month and 1-year check. The TEP scanner performed at 6 months showed a decrease in the vertebral hypermetabolism L3-L4 (lumbar SUV 4.4 vs hepatic SUV 2.74) but the persistence of a major hypermetabolism at the level of the bypass (bypass SUV 4.25 vs hepatic SUV 2.74). More than a year after the start of the treatment, the patient is still asymptomatic; regular monitoring alone was proposed.\n", + "fulltext_subclaims": [ + "The patient is a 69-year-old man.", + "He was admitted for the exploration of a progressive deterioration of his general condition.", + "He had inflammatory-like low back pain for several weeks.", + "He reported a progressive weight loss of 15 kg over the last 3 months.", + "He lived in sub-Saharan Africa for 20 years in rural areas.", + "His medical history included HIV infection controlled with a tritherapy (emtricitabine, rilpivirine, tenofovir alafenamide).", + "He had severe osteoporotic fractures in the vertebrae and sternum.", + "He was treated with oral bisphosphonates with good compliance.", + "He was an active smoker with more than 50 pack-years.", + "He had obliterative arteriosclerosis of the lower limbs.", + "He had a femoro-femoral bypass in 2016.", + "The initial clinical examination showed camptocormia.", + "There was invalidating lumbar pain.", + "There was a moderate inflammatory biological syndrome with a CRP of 42 mg/L.", + "There was a moderate inflammatory anaemia.", + "There was a discrete neutrophil increase (8.73 G/L).", + "There was cholestasis without cytolysis.", + "The HIV viral load was undetectable.", + "The CD4+ T lymphocyte count was 474/μL.", + "A thoraco-abdomino-pelvic scan revealed an abscessed L3–L4 spondylodiscitis.", + "An MRI confirmed the diagnosis of spondylodiscitis with left paravertebral abscess.", + "The peripheral infectious samples with blood cultures were all negative.", + "A transthoracic echocardiography did not allow visualisation of vegetations.", + "A PET-CT with cardiac preparation was performed.", + "The PET-CT revealed a L3–L4 hypermetabolism (SUV L3–L4 8.1).", + "The PET-CT also revealed an intense fixation at the femoral-femoral crossover bridge (SUV crossover 4.14).", + "The absence of valvular fixation allowed the exclusion of associated inflammatory endocarditis.", + "A discolumbo-vertebral biopsy was performed.", + "The bacterial culture from the biopsy was negative.", + "The universal PCR (16S RNA) from the biopsy was negative.", + "The histology could not be performed due to insufficient material.", + "The search for Mycobacterium tuberculosis in PCR and culture was negative.", + "Serology for C. burnetii was requested.", + "The result was in favour of a chronic Q fever (phase I, IgG 4093).", + "The specific PCR for C. burnetii on the disco-vertebral biopsy material was positive.", + "The blood PCR for C. burnetii was negative.", + "The diagnosis of chronic Q fever with an abscessed L3-L4 spondylodiscitis and a femoro-femoral bypass infection was retained.", + "The choice of a long-term treatment with hydroxychloroquine 600 mg and doxycycline 200 mg daily was initiated.", + "The clinical evolution was favorable with a recovery of walking.", + "After two weeks of treatment, the biological inflammatory syndrome was completely negative.", + "The IgG C. burnetii serology of phase 1 had decreased from a titre at 3 months.", + "The TEP scanner performed at 6 months showed a decrease in the vertebral hypermetabolism L3-L4.", + "The TEP scanner showed the persistence of a major hypermetabolism at the level of the bypass.", + "More than a year after the start of the treatment, the patient is still asymptomatic." + ], + "summary": "We report the case of a 69-year-old man who presented to Internal Medicine for a general condition associated with lower back pain. His main comorbidities were a HIV infection and a femoro-femoral bypass for obliterative arteritis of the lower limbs. A CT scan revealed an abscessed spondylodiscitis L3-L4, but all infectious samples with prolonged blood cultures were negative. A transthoracic ultrasound scan for infectious endocarditis was normal. A PET scan detected a vertebral hypermetabolism L3-L4 associated with a significant hypermetabolism of the femoro-femoral bypass. The serology for C. burnetii was in favour of a chronic Q fever. The therapeutic management required a multidisciplinary medical-surgical discussion. Three months later, the serology was reduced by one titre and stabilised at this titre at 6 months and 1 year.\n", + "summary_subclaims": [ + "The patient was a 69-year-old man.", + "He presented to Internal Medicine for a general condition associated with lower back pain.", + "His main comorbidities were an HIV infection and a femoro-femoral bypass for obliterative arteritis of the lower limbs.", + "A CT scan revealed an abscessed spondylodiscitis L3-L4.", + "All infectious samples with prolonged blood cultures were negative.", + "A transthoracic ultrasound scan for infectious endocarditis was normal.", + "A PET scan detected a vertebral hypermetabolism L3-L4.", + "The PET scan showed a significant hypermetabolism of the femoro-femoral bypass.", + "The serology for C. burnetii was in favour of a chronic Q fever.", + "The therapeutic management required a multidisciplinary medical-surgical discussion.", + "Three months later, the serology was reduced by one titre.", + "The serology stabilised at this titre at 6 months and 1 year." + ] + }, + { + "id": "multiclinsum_test_1168_en.txt", + "fulltext": "A 39-year-old Caucasian man presented in 2009 with an 8-week history of fevers, night sweats, nausea, abdominal pain and distension and 5 kg weight loss. He reported no respiratory or other gastrointestinal symptoms and did not have any unwell contacts or history of overseas travel. He cared for an aviary of Gouldian finches (Erythrura gouldiae), which included cleaning and removing dead birds. There is no personal or family history of recurrent or opportunistic infections.\nThree years earlier, he was diagnosed with acetylcholine receptor (AChR) antibody-positive myasthenia gravis (MG) after presenting with ptosis, dysarthria and dysphagia. A type B2 thymoma was confirmed on surgical resection and treatment with prednisolone and pyridostigmine was commenced.\nIn 2008, he suffered a myasthenic crisis with severe bulbar and respiratory muscle involvement necessitating a feeding tube (Myasthenia Gravis Foundation of America (MGFA) grade 4b). This improved with treatment (3-weekly plasma exchange, cyclosporine 150 mg two times per day, azathioprine 50 mg daily and prednisolone 25 mg alternate days) and he remained clinically stable until this presentation. At presentation, he had mild residual bulbar features, including dysarthria, dysphagia and fatigable chewing.\nOn examination, he was afebrile, and had splenomegaly, periumbilical and epigastric tenderness. There was no palpable lymphadenopathy.\nFull blood examination showed haemoglobin of 111 g/L (130–170 g/L) and lymphocytes of 1.0×109/L (1.2–2.7 x 109 /L). C reactive protein was 63 mg/L.\nLymphocyte subsets, including CD4 T-cell counts, were all within normal limits except for reduced CD19 pan B-cell count at 0.03×109/L (0.05–0.41×109/L). Immunoglobulin levels were not reduced, and HIV screen was negative. Bacterial and mycobacterial blood cultures were unrevealing.\nCT scan demonstrated splenomegaly (15 cm) and periaortic and mesenteric lymphadenopathy with no evidence of thymoma recurrence or residual thymic tissue. Gastroscopy showed a macroscopically abnormal duodenum with a fine, nodular appearance. Gastric and duodenal biopsies revealed broad, shortened villi and marked diffuse to confluent infiltrates of histiocytes in the lamina propria. Innumerable acid-fast bacilli were seen on Ziehl-Neelsen stain . Mycobacterium genavense was identified on molecular sequencing, leading to a diagnosis of disseminated M. genavense infection in an immunocompromised patient. Empirical therapy with rifampicin, ethambutol, moxifloxacin and clarithromycin was started. Cyclosporine and azathioprine were discontinued and the frequency of plasma exchange was increased with sequential intravenous immunoglobulin.\nDespite treatment, interval abdominal CT scan revealed progressive splenomegaly (17.8 cm) and intra-abdominal lymphadenopathy, raising concerns of refractory infection or lymphoma, as well as potential splenic rupture. Further biopsies of the mesenteric lymph nodes, stomach and duodenum demonstrated countless mycobacteria, consistent with ongoing infection. Drug sensitivities were unavailable as M. genavense could not be cultured.\nFollowing a multidisciplinary discussion, subcutaneous interferon-gamma (IFN-γ) was trialled, resulting in substantial fever. Dose was reduced to induce only low-grade fevers and chills (25 μg three times a week). Over the next 12 months, the patient’s symptoms resolved. Repeat CT scan demonstrated a reduction in the degree of splenomegaly and intra-abdominal lymphadenopathy. Antimicrobials were slowly weaned off over 6 years and he remains well 11 years later, with controlled myasthenia.\nGiven the rare opportunistic infection, stored and newly collected blood samples were investigated for cytokine antibodies producing immunodeficiency. Due to ease of use and wide availability, the tuberculosis IFN-γ release assay was used to screen for reduced IFN-γ production. After incubation, a multiplex assay was used to measure cytokine production within the supernatant. The patient’s sample showed a markedly reduced IFN-γ response to mitogen stimulation compared with healthy controls . Moreover, the analysis also revealed a reduced concentration of interleukin-12 (IL-12).\nResearch-based inhibition studies showed that adding the patient’s sample to IL-12p40 resulted in inhibition of analyte recovery at sample concentrations above 1:16 , suggesting the presence of an IL-12p40 inhibitor. This inhibitory effect was similar to that seen with ustekinumab, a human monoclonal antibody specifically directed against the p40 subunit shared by IL-12 and IL-23. Interestingly, plasma exchange did not substantially reduce inhibition , suggesting that the patient had a very high inhibitor concentration.", + "fulltext_subclaims": [ + "The patient is a 39-year-old Caucasian man.", + "He presented in 2009 with an 8-week history of fevers, night sweats, nausea, abdominal pain and distension, and 5 kg weight loss.", + "He reported no respiratory or other gastrointestinal symptoms.", + "He had no history of overseas travel.", + "He cared for an aviary of Gouldian finches.", + "Three years earlier, he was diagnosed with acetylcholine receptor (AChR) antibody-positive myasthenia gravis.", + "A type B2 thymoma was confirmed on surgical resection.", + "In 2008, he suffered a myasthenic crisis with severe bulbar and respiratory muscle involvement.", + "This improved with treatment including 3-weekly plasma exchange, cyclosporine 150 mg two times per day, azathioprine 50 mg daily, and prednisolone 25 mg alternate days.", + "At presentation, he had mild residual bulbar features, including dysarthria, dysphagia, and fatigable chewing.", + "On examination, he had splenomegaly and periumbilical and epigastric tenderness.", + "Full blood examination showed haemoglobin of 111 g/L.", + "Lymphocytes were 1.0×109/L.", + "C reactive protein was 63 mg/L.", + "CD19 pan B-cell count was 0.03×109/L.", + "Immunoglobulin levels were not reduced.", + "HIV screen was negative.", + "Bacterial and mycobacterial blood cultures were unrevealing.", + "CT scan demonstrated splenomegaly (15 cm) and periaortic and mesenteric lymphadenopathy.", + "Gastroscopy showed a macroscopically abnormal duodenum with a fine, nodular appearance.", + "Gastric and duodenal biopsies revealed broad, shortened villi and marked diffuse to confluent infiltrates of histiocytes in the lamina propria.", + "Innumerable acid-fast bacilli were seen on Ziehl-Neelsen stain.", + "Mycobacterium genavense was identified on molecular sequencing.", + "Empirical therapy with rifampicin, ethambutol, moxifloxacin, and clarithromycin was started.", + "Cyclosporine and azathioprine were discontinued.", + "The frequency of plasma exchange was increased with sequential intravenous immunoglobulin.", + "Despite treatment, interval abdominal CT scan revealed progressive splenomegaly (17.8 cm) and intra-abdominal lymphadenopathy.", + "Further biopsies of the mesenteric lymph nodes, stomach, and duodenum demonstrated countless mycobacteria.", + "Drug sensitivities were unavailable as M. genavense could not be cultured.", + "Subcutaneous interferon-gamma (IFN-γ) was trialled, resulting in substantial fever.", + "The dose was reduced to induce only low-grade fevers and chills (25 μg three times a week).", + "Over the next 12 months, the patient’s symptoms resolved.", + "Repeat CT scan demonstrated a reduction in the degree of splenomegaly and intra-abdominal lymphadenopathy.", + "Antimicrobials were slowly weaned off over 6 years.", + "The patient remains well 11 years later, with controlled myasthenia.", + "Stored and newly collected blood samples were investigated for cytokine antibodies producing immunodeficiency.", + "The tuberculosis IFN-γ release assay was used to screen for reduced IFN-γ production.", + "The patient’s sample showed a markedly reduced IFN-γ response to mitogen stimulation compared with healthy controls.", + "The analysis also revealed a reduced concentration of interleukin-12 (IL-12).", + "Research-based inhibition studies showed that adding the patient’s sample to IL-12p40 resulted in inhibition of analyte recovery at sample concentrations above 1:16.", + "The inhibitory effect was similar to that seen with ustekinumab.", + "Plasma exchange did not substantially reduce inhibition.", + "This suggests the patient had a very high inhibitor concentration." + ], + "summary": "A 39-year-old man with thymoma-associated acetylcholine receptor antibody myasthenia gravis (MG) presented with fevers, night sweats, abdominal pain and weight loss. Marked splenomegaly and intra-abdominal lymphadenopathy were found. Biopsies confirmed disseminated Mycobacterium genavense infection. Despite antimicrobials and reduced immunosuppressive medications, he worsened. We suspected a thymoma-associated cytokine inhibitory antibody. The addition of subcutaneous interferon-gamma (IFN-γ) induced clinical and radiological improvement. His antimicrobials were able to be ceased. MG remained stable. Subsequent testing demonstrated an endogenous interleukin-12 (IL-12) inhibitor, likely inhibiting the IL-12/IFN-γ axis crucial for defence against mycobacterial infections.", + "summary_subclaims": [ + "The patient is a 39-year-old man.", + "The patient has thymoma-associated acetylcholine receptor antibody myasthenia gravis.", + "The patient presented with fevers.", + "The patient presented with night sweats.", + "The patient presented with abdominal pain.", + "The patient presented with weight loss.", + "Marked splenomegaly was found.", + "Intra-abdominal lymphadenopathy was found.", + "Biopsies confirmed disseminated Mycobacterium genavense infection.", + "The patient was treated with antimicrobials.", + "The patient's immunosuppressive medications were reduced.", + "The patient worsened despite antimicrobials and reduced immunosuppressive medications.", + "We suspected a thymoma-associated cytokine inhibitory antibody.", + "Subcutaneous interferon-gamma was added.", + "Subcutaneous interferon-gamma induced clinical improvement.", + "Subcutaneous interferon-gamma induced radiological improvement.", + "Antimicrobials were able to be ceased.", + "MG remained stable.", + "Subsequent testing demonstrated an endogenous interleukin-12 inhibitor.", + "The IL-12/IFN-γ axis is crucial for defence against mycobacterial infections." + ] + }, + { + "id": "multiclinsum_test_1555_en.txt", + "fulltext": "A 47-year-old male patient was admitted with esophagogastric hemorrhage secondary to portal hypertension derived from decompensated cirrhosis. At the initial consultation, his chief complaint was hematemesis and two episodes of melena. His past medical history was viral hepatitis B with HBsAg + and HBcAb + for more than 10 years, and his surgical history included splenectomy and periesophagogastric devascularization for portal hypertension, hypersplenism and splenomegaly, and cholecystectomy for gallstones one year before, at a different hospital. His vital signs were as follows: temperature, 36.7 °C; blood pressure, 120/68 mmHg; respiratory rate, 20; and heart rate, 84. He had scleral icterus in both eyes. Physical examination showed negative chest and cardiac findings. Tenderness and rebound pain was marked, and shift dullness was remarkable. His blood work results were as follows: white blood cell count, 16.6 × 109/l; red blood cell count, 2.47 × 1012/l; platelet cell count, 183 × 109/l; and hemoglobin, 67 g/l. Stool hemoccult test results were positive (+++). His liver function profile was as follows: total bilirubin, 84 μmol/l; ALT, 319; AST, 347; albumin, 32.3 g⁄l; C-reactive protein, 107 mg/l; alpha-fetoprotein, normal; carcinoembryonic antigen concentration test, normal; and amylase, unremarkable. The patient’s coagulopathy parameters were as follows: PT, 19.3 s; PT%, 43.6 %; fibrinogen, 1.4 g/l; APTT, 120.9 s; and TT, 21.3 s.\nParacentesis fluid revealed serosanguinous ascites, and bacterial culture showed that no bacteria were present. Enhanced computerized tomography results showed hepatic nodular regeneration, moderate ascites, a dilated bowel, and emboli in the portal vein and the superior mesenteric vein that extended to the distal and tributary veins . Melena and hematemesis reoccurred after administering coagulants including thrombase and tranexamic acid, which were administered for a few days. The patient was moved to transplant surgery to await a donated liver.\nTwo days later, the liver from a 35-year-old deceased male with ABO-compatibility was available, and liver transplantation and thrombectomy were planned. After entry into the abdominal cavity, approximately 2.5 l of ascites was removed using suction. The abdominal cavity was explored; the liver had several nodules, the spleen and gall bladder had been excised, complete occlusion of the portal vein and the superior mesenteric vein (Grade III-IV) was found, and two segments of the proximal jejunum were purplish-black in color. A short distal vein arcade was fully occluded, and there was intestinal necrosis with intestinal tone and no perforation . Ascites culture results were negative, which suggested that there was no bacterial translocation. Intra-operative ultrasound confirmed the permeability of the superior mesenteric artery, which had a palpable pulse. Further histology results showed nodular hyperplasia that excluded small cancer. Orthotopic LT was then performed using a piggy-back caval anastomosis, and portal vein eversion was then conducted to remove the thrombi in the portal and superior mesenteric veins. These veins were cavernous, with numerous small thrombi that were flushed out via blood flow. Portal venous blood flow was restored and confirmed intra-operatively using a Doppler ultrasonic flow meter (data not shown), and 25 units of plasma and packed red cells were transfused. Approximately 100 cm of gangrenous jejunum was subsequently resected from Treitz’s ligament, and an end-to-end anastomosis of the jejunum was performed to maintain intestinal continuity. The patient recovered fully, although a fistula occurred, which resolved upon draining.\nMedications such as the following were administered: immunosuppressive therapy to treat immune rejection, potent broad-spectrum antibiotics to treat potential infection, anti-coagulant agents to treat re-embolism, and lamivudine and immunoglobulin to prevent hepatitis B viral infection recurrence. The allograft functioned well, and ALT, AST and bilirubin levels decreased daily, while albumin levels increased. Thirteen days after OLT, a fistula occurred in the anastomosis, and laparoscopic surgery was performed again to allow suction and access to the abdominal cavity. A 4-cm mushroom-shaped tube was inserted into the near jejunum to allow drainage, and a feeding tube was also inserted into the distal intestine. After about 3 weeks, the patient was recovering well. Seventy months after surgery, the patient’s allograft was functioning well and his medical history has been uneventful.", + "fulltext_subclaims": [ + "The patient was a 47-year-old male.", + "The patient was admitted with esophagogastric hemorrhage.", + "The hemorrhage was secondary to portal hypertension.", + "The portal hypertension was derived from decompensated cirrhosis.", + "The patient had hematemesis.", + "The patient had two episodes of melena.", + "The patient had a past medical history of viral hepatitis B.", + "The patient had HBsAg + for more than 10 years.", + "The patient had HBcAb + for more than 10 years.", + "The patient had a surgical history of splenectomy.", + "The patient had a surgical history of periesophagogastric devascularization.", + "The patient had a surgical history of cholecystectomy.", + "The cholecystectomy was for gallstones.", + "The cholecystectomy occurred one year before admission.", + "The cholecystectomy was at a different hospital.", + "The patient's blood pressure was 120/68 mmHg.", + "The patient had scleral icterus in both eyes.", + "Tenderness and rebound pain were marked.", + "Shift dullness was remarkable.", + "The white blood cell count was 16.6 × 109/l.", + "The red blood cell count was 2.47 × 1012/l.", + "The platelet cell count was 183 × 109/l.", + "The hemoglobin was 67 g/l.", + "The stool hemoccult test was positive (+++).", + "The total bilirubin was 84 μmol/l.", + "The ALT was 319.", + "The AST was 347.", + "The albumin was 32.3 g/l.", + "The C-reactive protein was 107 mg/l.", + "The alpha-fetoprotein was normal.", + "The carcinoembryonic antigen concentration test was normal.", + "The amylase was unremarkable.", + "The PT was 19.3 s.", + "The PT% was 43.6 %.", + "The fibrinogen was 1.4 g/l.", + "The APTT was 120.9 s.", + "The TT was 21.3 s.", + "Paracentesis fluid was serosanguinous.", + "Bacterial culture of the ascites was negative.", + "Enhanced computerized tomography showed hepatic nodular regeneration.", + "Enhanced computerized tomography showed moderate ascites.", + "Enhanced computerized tomography showed a dilated bowel.", + "Enhanced computerized tomography showed emboli in the portal vein.", + "Enhanced computerized tomography showed emboli in the superior mesenteric vein.", + "The emboli extended to the distal and tributary veins.", + "Melena and hematemesis reoccurred after administering coagulants.", + "The coagulants included thrombase and tranexamic acid.", + "The coagulants were administered for a few days.", + "The patient was moved to transplant surgery to await a donated liver.", + "Two days later, a liver from a 35-year-old deceased male was available.", + "The donor liver was ABO-compatible.", + "Liver transplantation and thrombectomy were planned.", + "Approximately 2.5 l of ascites was removed using suction.", + "The abdominal cavity was explored.", + "The liver had several nodules.", + "The spleen had been excised.", + "The gall bladder had been excised.", + "Complete occlusion of the portal vein and superior mesenteric vein was found.", + "The occlusion was Grade III-IV.", + "Two segments of the proximal jejunum were purplish-black in color.", + "A short distal vein arcade was fully occluded.", + "There was intestinal necrosis.", + "There was no intestinal perforation.", + "Ascites culture results were negative.", + "The negative culture suggested no bacterial translocation.", + "Intra-operative ultrasound confirmed the permeability of the superior mesenteric artery.", + "The superior mesenteric artery had a palpable pulse.", + "Further histology showed nodular hyperplasia.", + "The histology excluded small cancer.", + "Orthotopic liver transplantation was performed.", + "A piggy-back caval anastomosis was used.", + "Portal vein eversion was conducted.", + "The thrombi in the portal and superior mesenteric veins were removed.", + "The veins were cavernous.", + "Numerous small thrombi were flushed out via blood flow.", + "Portal venous blood flow was restored.", + "Portal venous blood flow was confirmed intra-operatively using a Doppler ultrasonic flow meter.", + "25 units of plasma were transfused.", + "25 units of packed red cells were transfused.", + "Approximately 100 cm of gangrenous jejunum was resected.", + "An end-to-end anastomosis of the jejunum was performed.", + "The patient recovered fully.", + "A fistula occurred.", + "The fistula resolved upon draining.", + "Immunosuppressive therapy was administered.", + "Potent broad-spectrum antibiotics were administered.", + "Anti-coagulant agents were administered.", + "Lamivudine was administered.", + "Immunoglobulin was administered.", + "The allograft functioned well.", + "ALT, AST, and bilirubin levels decreased daily.", + "Albumin levels increased.", + "Thirteen days after OLT, a fistula occurred in the anastomosis.", + "Laparoscopic surgery was performed again.", + "A 4-cm mushroom-shaped tube was inserted into the near jejunum.", + "A feeding tube was inserted into the distal intestine.", + "After about 3 weeks, the patient was recovering well.", + "Seventy months after surgery, the patient’s allograft was functioning well.", + "The patient’s medical history has been uneventful." + ], + "summary": "A 47-year-old man presented with hematemesis and melena, and a diagnosis of decompensated cirrhosis, chronic portal vein thrombosis (PVT) and secondary gastro-esophageal variceal hemorrhage was made. Coagulants were administered, but portal vein thrombi occurred rapidly, and gastrointestinal bleeding recurred shortly thereafter. The patient underwent LT, phlebothrombectomy and a partial jejunectomy. His recovery from a fistula was uneventful, and follow-up visits over 70 months were unremarkable.", + "summary_subclaims": [ + "The patient is a 47-year-old man.", + "The patient presented with hematemesis and melena.", + "A diagnosis of decompensated cirrhosis was made.", + "A diagnosis of chronic portal vein thrombosis was made.", + "A diagnosis of secondary gastro-esophageal variceal hemorrhage was made.", + "Coagulants were administered.", + "Portal vein thrombi occurred rapidly.", + "Gastrointestinal bleeding recurred shortly after administration of coagulants.", + "The patient underwent liver transplantation.", + "The patient underwent phlebothrombectomy.", + "The patient underwent a partial jejunectomy.", + "The patient's recovery from a fistula was uneventful.", + "Follow-up visits over 70 months were unremarkable." + ] + }, + { + "id": "multiclinsum_test_2933_en.txt", + "fulltext": "A 51-year-old male was transferred to our hospital after an out-of-hospital cardiac arrest. He had family history of sudden cardiac death in one brother with autopsy study that reported normal cardiac findings, and genetic test was not performed. Moreover, he had a body mass index of 28.5, and medical history of uncomplicated renal colic, otherwise there was no more relevant medical history in their electronic health record system. In this regard, his family denied medical history of hypertension, diabetes, dyslipidemia, allergies, smoking and illicit drugs. In addition, his family states that he used to drink 1–2 alcoholic drinks each week. He had no prescription medication, over-the-counter medications or supplements. Regarding his social history, he was of Caucasian and Hispanic ethnicity, and his occupation was computer engineering. Based on his income, he was on middle social class. He lived independently with his wife and two children. Furthermore, he had received the first dose of the vaccine Ad26.COV2.S (Janssen®) against COVID-19 48 h ago. His family admitted that the patient stated asthenia, myalgias, atypical chest discomfort, and low-grade fever (37,4 °C) in the last 24 h.\nThe patient had a witnessed collapse by his son, and basic cardiopulmonary resuscitation was started by the local police. An automated external defibrillator advised shock, and he was defibrillated twice. Then, 15 min later, paramedics arrived and found the patient in ventricular fibrillation, advanced cardiopulmonary resuscitation was performed by mechanical chest compressions (Lucas®), pulse activity was restored, an ECG showed atrial fibrillation with ST elevation in V1-V2, AVR, and diffuse ST depression in all the leads. During ambulance transportation, the patient had several ventricular fibrillation episodes that were defibrillated and finally came out in asystole. After approximately 1.5 h since the patient experienced a sudden cardiac arrest and 75 min of advanced cardiopulmonary resuscitation, of which 45 min were in asystole, the patient arrived at our center. On admission, the patient was unconscious and in asystole rhythm. Bedside echocardiography ruled out pericardial effusion and pneumothorax.\nThe coronary angiography was performed by the senior interventional cardiologists. A 6-Fr sheath was introduced into the right femoral artery and another 6-Fr sheath in the right femoral vein. A JL 4 guide catheter 6-Fr was placed over the wire into the ascending aorta, and the left coronary artery was cannulated; it was patent, and there were non-obstructive coronary arteries . Then, the catheter was exchanged for a JR 4 guide catheter 6-Fr, while the right coronary artery was cannulated, an image of probable aortic dissection was observed . The right coronary artery was patent and without angiographic stenosis . Given the persistent asystole despite a prolonged advance cardiopulmonary resuscitation and the possibility of aortic dissection, a prompt in-room heart team discussion was performed with the senior cardiac surgeons. It was decided to stop and withdraw potentially life-sustaining treatment due to futility. Of the note, the SARS-CoV-2 RT-PCR test was negative. In addition, genetic testing and necropsy were performed with the consent of his family. The genetic testing reported a negative result for explaining the sudden cardiac death. On the other hand, the aorta in the necropsy study revealed some mild atherosclerotic plaques but without either aneurysm or thrombosis (, , ). The coronary arteries were reported as with patency. In the proximal left anterior descending artery (LAD), the intima layer presented a thickness that decreased 50 % of the luminal area, with mild calcification and macrophages but without complicated acute plaques such as rupture, erosion, or thrombus. For the rest, the necropsy study was reported as without relevant pathologies. This case report has been reported in line with SCARE 2020 criteria .", + "fulltext_subclaims": [ + "The patient was a 51-year-old male.", + "The patient had an out-of-hospital cardiac arrest.", + "The patient had a family history of sudden cardiac death in one brother.", + "The brother's autopsy study reported normal cardiac findings.", + "The brother's genetic test was not performed.", + "The patient had a body mass index of 28.5.", + "The patient had a medical history of uncomplicated renal colic.", + "The patient's electronic health record system did not show other relevant medical history.", + "The patient's family denied medical history of hypertension.", + "The patient's family denied medical history of diabetes.", + "The patient's family denied medical history of dyslipidemia.", + "The patient's family denied medical history of allergies.", + "The patient's family denied medical history of smoking.", + "The patient's family denied medical history of illicit drugs.", + "The patient's family states he used to drink 1–2 alcoholic drinks each week.", + "The patient had no prescription medication.", + "The patient had no over-the-counter medications.", + "The patient had no supplements.", + "The patient was of Caucasian and Hispanic ethnicity.", + "The patient's occupation was computer engineering.", + "The patient was on middle social class.", + "The patient lived independently with his wife and two children.", + "The patient had received the first dose of the vaccine Ad26.COV2.S (Janssen®) against COVID-19 48 h before the cardiac arrest.", + "The patient's family admitted he had asthenia in the last 24 h.", + "The patient's family admitted he had myalgias in the last 24 h.", + "The patient's family admitted he had atypical chest discomfort in the last 24 h.", + "The patient's family admitted he had low-grade fever (37,4 °C) in the last 24 h.", + "The patient had a witnessed collapse by his son.", + "Basic cardiopulmonary resuscitation was started by the local police.", + "An automated external defibrillator advised shock.", + "The patient was defibrillated twice.", + "Paramedics arrived 15 min after the collapse.", + "Paramedics found the patient in ventricular fibrillation.", + "Advanced cardiopulmonary resuscitation was performed by mechanical chest compressions (Lucas®).", + "Pulse activity was restored.", + "An ECG showed atrial fibrillation with ST elevation in V1-V2, AVR, and diffuse ST depression in all the leads.", + "During ambulance transportation, the patient had several ventricular fibrillation episodes.", + "The patient arrived at the hospital in asystole.", + "The patient had approximately 1.5 h since the sudden cardiac arrest.", + "The patient had 75 min of advanced cardiopulmonary resuscitation.", + "Of the 75 min of advanced cardiopulmonary resuscitation, 45 min were in asystole.", + "On admission, the patient was unconscious.", + "On admission, the patient was in asystole rhythm.", + "Bedside echocardiography ruled out pericardial effusion.", + "Bedside echocardiography ruled out pneumothorax.", + "The coronary angiography was performed by senior interventional cardiologists.", + "A 6-Fr sheath was introduced into the right femoral artery.", + "A 6-Fr sheath was introduced into the right femoral vein.", + "A JL 4 guide catheter 6-Fr was placed over the wire into the ascending aorta.", + "The left coronary artery was cannulated.", + "The left coronary artery was patent.", + "The coronary arteries were non-obstructive.", + "The catheter was exchanged for a JR 4 guide catheter 6-Fr.", + "The right coronary artery was cannulated.", + "An image of probable aortic dissection was observed.", + "The right coronary artery was patent.", + "The right coronary artery had no angiographic stenosis.", + "A prompt in-room heart team discussion was performed with senior cardiac surgeons.", + "Potentially life-sustaining treatment was stopped and withdrawn due to futility.", + "The SARS-CoV-2 RT-PCR test was negative.", + "Genetic testing was performed with the consent of his family.", + "Genetic testing reported a negative result for explaining the sudden cardiac death.", + "The aorta in the necropsy study revealed some mild atherosclerotic plaques.", + "The aorta in the necropsy study had no aneurysm.", + "The aorta in the necropsy study had no thrombosis.", + "The coronary arteries were reported as patent.", + "The proximal left anterior descending artery (LAD) intima layer had a thickness that decreased 50% of the luminal area.", + "The proximal LAD had mild calcification.", + "The proximal LAD had macrophages.", + "The proximal LAD had no complicated acute plaques such as rupture, erosion, or thrombus.", + "The necropsy study was reported as without relevant pathologies.", + "This case report has been reported in line with SCARE 2020 criteria." + ], + "summary": "We report a case of a middle-aged man transferred to our hospital after an out-of-hospital cardiac arrest. The coronary angiography revealed non-obstructive coronary arteries and an image of probable aortic dissection was observed. Given the persistent asystole despite a prolonged advance cardiopulmonary resuscitation and the possibility of aortic dissection, a prompt in-room heart team discussion was performed. It was decided to stop and withdraw potentially life-sustaining treatment due to futility. The necropsy study revealed the aorta with some mild atherosclerotic plaques but without either aneurysm or thrombosis. The coronary arteries were reported as with patency, but in the proximal left anterior descending artery (LAD), the intima layer presented a thickness that decreased 50 % of the luminal area without signs of complicated acute plaques.", + "summary_subclaims": [ + "The patient was a middle-aged man.", + "The patient was transferred to the hospital after an out-of-hospital cardiac arrest.", + "The coronary angiography revealed non-obstructive coronary arteries.", + "An image of probable aortic dissection was observed.", + "The patient had persistent asystole despite a prolonged advanced cardiopulmonary resuscitation.", + "A prompt in-room heart team discussion was performed.", + "It was decided to stop and withdraw potentially life-sustaining treatment due to futility.", + "The necropsy study revealed the aorta with some mild atherosclerotic plaques.", + "The necropsy study showed no aneurysm.", + "The necropsy study showed no thrombosis.", + "The coronary arteries were reported as patent.", + "The intima layer in the proximal left anterior descending artery (LAD) presented a thickness that decreased 50% of the luminal area.", + "There were no signs of complicated acute plaques in the proximal LAD." + ] + }, + { + "id": "multiclinsum_test_2228_en.txt", + "fulltext": "A 68 year-old male patient was referred to our surgical department from another hospital's medical department with a presenting clinical picture of sudden right upper quadrant abdominal pain, nausea and dark urine. With an initial diagnosis of obstructive jaundice possibly due to choledocholithiasis the patient was admitted to our department for further investigation. The patient's past medical history included upper gastrointestinal bleeding and chronic pulmonary obstructive disease.\nTumor markers (CEA, CA19-9, a-FP) were normal, while a mild elevation of the cholestatic enzymes (ALP = 138 IU/L, γ-GT = 95 IU/L) were demonstrated with return to normal of bilirubin and transaminases.\nAbdominal ultrasound, computed tomography and magnetic resonance imaging demonstrated dilatation of the left intrahepatic bile ducts without the presence of any space-occupying lesion. Triplex ultrasonography of the liver confirmed the patency of portal and hepatic veins and of the hepatic artery.\nEndoscopic retrograde and magnetic resonance cholangio-pancreatographies showed anomalous dilatation of the left intrahepatic bile ducts with a concomitant milder dilatation of the pancreatic duct, as well as mucus discharge from the papilla of Vater during endoscopy.\nColonoscopy was performed to rule out primary bowel neoplasm and revealed the presence of large bowel polyps. Snare polypectomies were performed and the histological analysis demonstrated the presence of tubulous and tubulovillous adenomas of the colon with mild to moderate degree of epithelial dysplasia.\nTotal bone scan with Tc99 m MDP, thoracic computed tomography and brain magnetic resonance imaging were negative for secondary deposits.\nWith a diagnosis of a cholangiocarcinoma a left hepatectomy with inflow occlusion (Pringle's maneuver) and selective hepatic vascular exclusion and cholecystectomy were carried out. The histology report describes the presence of foci of papillary adenomas with a fibrovascular core connecting each of them with the ductal wall, the cuboidal or columnar cells lining the bile duct epithelium and the presence of excessive intraductal mucus, as well as foci of a moderately to poorly differentiated carcinoma, with sporadic necrotic areas and invasion of the fibrously thickened intrahepatic bile ducts .\nThe postoperative course was uneventful and the patient was discharged on the 9th postoperative day. Despite an uncomplicated 2 year follow-up period, the patient rapidly deteriorated and died from multiple pulmonary metastatic deposits.", + "fulltext_subclaims": [ + "The patient was a 68 year-old male.", + "The patient was referred to the surgical department from another hospital's medical department.", + "The presenting clinical picture included sudden right upper quadrant abdominal pain.", + "The presenting clinical picture included nausea.", + "The presenting clinical picture included dark urine.", + "The initial diagnosis was obstructive jaundice.", + "The initial diagnosis suggested choledocholithiasis as a possible cause.", + "The patient was admitted for further investigation.", + "The patient's past medical history included upper gastrointestinal bleeding.", + "The patient's past medical history included chronic pulmonary obstructive disease.", + "Tumor markers (CEA, CA19-9, a-FP) were normal.", + "Cholestatic enzymes were mildly elevated.", + "ALP was 138 IU/L.", + "γ-GT was 95 IU/L.", + "Bilirubin returned to normal.", + "Transaminases returned to normal.", + "Abdominal ultrasound showed dilatation of the left intrahepatic bile ducts.", + "Computed tomography showed dilatation of the left intrahepatic bile ducts.", + "Magnetic resonance imaging showed dilatation of the left intrahepatic bile ducts.", + "No space-occupying lesion was present.", + "Triplex ultrasonography confirmed the patency of portal and hepatic veins.", + "Triplex ultrasonography confirmed the patency of the hepatic artery.", + "Endoscopic retrograde cholangio-pancreatography showed anomalous dilatation of the left intrahepatic bile ducts.", + "Magnetic resonance cholangio-pancreatography showed anomalous dilatation of the left intrahepatic bile ducts.", + "Magnetic resonance cholangio-pancreatography showed milder dilatation of the pancreatic duct.", + "Mucus discharge from the papilla of Vater was observed during endoscopy.", + "Colonoscopy revealed the presence of large bowel polyps.", + "Snare polypectomies were performed.", + "Histological analysis showed tubulous and tubulovillous adenomas of the colon.", + "Histological analysis showed mild to moderate degree of epithelial dysplasia.", + "Total bone scan with Tc99 m MDP was negative for secondary deposits.", + "Thoracic computed tomography was negative for secondary deposits.", + "Brain magnetic resonance imaging was negative for secondary deposits.", + "A diagnosis of cholangiocarcinoma was made.", + "A left hepatectomy with inflow occlusion (Pringle's maneuver) was performed.", + "Selective hepatic vascular exclusion was performed.", + "A cholecystectomy was performed.", + "The histology report described the presence of foci of papillary adenomas.", + "The histology report described foci of moderately to poorly differentiated carcinoma.", + "The histology report described sporadic necrotic areas.", + "The histology report described invasion of the fibrously thickened intrahepatic bile ducts.", + "The postoperative course was uneventful.", + "The patient was discharged on the 9th postoperative day.", + "The patient had an uncomplicated 2 year follow-up period.", + "The patient rapidly deteriorated.", + "The patient died from multiple pulmonary metastatic deposits." + ], + "summary": "A 68 year-old male patient was referred to our hospital due to the presence of sudden right upper quadrant abdominal pain, nausea and dark urine. Imaging workup demonstrated dilatation of the left hepatic duct without the presence of a space-occupying lesion. A left hepatectomy and cholecystectomy were carried out and histological analysis revealed a moderately to poorly differentiated carcinoma of the left hepatic duct in the background of biliary papillomatosis. Postoperative course was uneventful. Unfortunately, two years after initial diagnosis the patient rapidly deteriorated and died from multiple pulmonary secondary deposits.", + "summary_subclaims": [ + "The patient was a 68 year-old male.", + "The patient was referred to the hospital due to sudden right upper quadrant abdominal pain.", + "The patient had nausea.", + "The patient had dark urine.", + "Imaging workup demonstrated dilatation of the left hepatic duct.", + "There was no space-occupying lesion.", + "A left hepatectomy was carried out.", + "A cholecystectomy was carried out.", + "Histological analysis revealed a moderately to poorly differentiated carcinoma of the left hepatic duct.", + "The carcinoma was in the background of biliary papillomatosis.", + "The postoperative course was uneventful.", + "Two years after initial diagnosis the patient rapidly deteriorated.", + "The patient died from multiple pulmonary secondary deposits." + ] + }, + { + "id": "multiclinsum_test_1134_en.txt", + "fulltext": "A 74-year-old Caucasian woman (patient 1) with no significant medical history presented with constant rotational vertigo, progressive gait ataxia with a tendency to fall to the right side and vertical diplopia increasing in right gaze. All symptoms were characterized by subacute onset with moderate progression over 6 months. Her elder sister, a 76-year-old Caucasian woman (patient 2) likewise presented with a 6-year-history of rotational vertigo, continuous gait ataxia and marked vertical diplopia. Symptoms were reported to have presented subacutely at onset and had initially been misdiagnosed as brainstem infarction.\nIn both patients, neurological examination revealed remarkably similar symptoms including gaze-evoked nystagmus and a slight abduction deficit of the right eye as well as ataxia and dysmetria in the upper and lower extremities with right-sided predominance. Because of the pronounced gait ataxia of both patients, they depended on a wheeled walker. Upon motor, reflex and sensory examination, no relevant findings were elicited, in particular no signs of dysarthria, peripheral neuropathy, spasticity, areflexia, vegetative symptoms or fasciculations that could have pointed to one of the hereditary ataxias, such as SCA1, 2, 3 and 6. Neuropsychological assessment did not reveal any substantial cognitive or memory deficits. Cerebral MRI findings showed mild generalized atrophy and multiple white matter lesions in both patients . Except for glycated hemoglobin (HbA1c) levels, which were expectably elevated due to the existing T1DM, all other routine laboratory examinations were within normal limits. Comprehensive workup with extended autoimmune laboratory examinations revealed remarkably high serum and CSF GAD-ab levels in both siblings . Other autoantibodies were negative, in particular antibodies against the NMDA, AMPA or GABA(B) receptor, LGI1, Caspr2, MAG, glycin receptor, or onconeuronal antibodies. Further CSF analysis showed slight pleocytosis in patient 1 and oligoclonal immunoglobulin bands in both patients.\nIn addition, the medical history of patient 1 revealed Hashimoto's thyroiditis with elevated serum antithyroid peroxidase antibody levels and recently diagnosed T1DM, whereas patient 2 exhibited a 7-year-history of Grave's disease with high levels of thyroid-stimulating immunoglobulins and a 6-year-history of insulin-dependent T1DM . Their family history revealed a 73-year-old brother suffering from rheumatism and another 75-year-old brother without relevant diseases.\nThe diagnosis of cerebellar ataxia with GAD-abs was established in both siblings based on the subacute onset, CSF inflammation in patient 1, the very high GAD-ab titers, the partial response to immunotherapy, the age at onset and the typical constellation of insulin-dependent diabetes. Because of these findings, no genetic testing was performed. Since the detection of GAD-abs can occasionally indicate a paraneoplastic etiology [, ], we undertook full-body computed tomography scans in both patients as well as whole-body and brain positron emission tomography in patient 1, all of which showed no pathological findings, suggesting the absence of any malignancy.\nPlasma separation by immunoadsorption was used to eliminate pathogenic antibodies from the serum compartment by binding to the extracorporeal columns. For this, patient 1 received 5 cycles every other day which led to subtle improvement of gait ataxia. Extended treatment with a further 10 cycles of immunoadsorption eventually resulted in remarkable improvement of gait which allowed the patient to walk without her walking frame. In patient 2, 7 cycles of plasmapheresis were administered every other day and resulted in subjective improvement of gait disability, and a slightly diminished degree of gaze-evoked nystagmus was seen on follow-up examination. However, relevant impairment persisted so that immunosuppressive therapy was escalated in both women to 1,000 mg rituximab intravenously according to common practice . Both patients gave their written informed consent for data analysis and the publication of this case report.", + "fulltext_subclaims": [ + "A 74-year-old Caucasian woman (patient 1) with no significant medical history presented with constant rotational vertigo.", + "The symptoms of patient 1 were characterized by subacute onset with moderate progression over 6 months.", + "Her elder sister, a 76-year-old Caucasian woman (patient 2), likewise presented with a 6-year-history of rotational vertigo.", + "In both patients, neurological examination revealed gaze-evoked nystagmus.", + "Cerebral MRI findings showed mild generalized atrophy in both patients.", + "Comprehensive workup with extended autoimmune laboratory examinations revealed remarkably high serum and CSF GAD-ab levels in both siblings.", + "Other autoantibodies were negative, in particular antibodies against the NMDA, AMPA or GABA(B) receptor.", + "The diagnosis of cerebellar ataxia with GAD-abs was established in both siblings.", + "Plasma separation by immunoadsorption was used to eliminate pathogenic antibodies from the serum compartment.", + "Patient 1 received 5 cycles of immunoadsorption every other day.", + "Extended treatment with a further 10 cycles of immunoadsorption eventually resulted in remarkable improvement of gait in patient 1.", + "Both patients gave their written informed consent for data analysis and the publication of this case report." + ], + "summary": "We report on 2 female siblings (aged 74 and 76 years) presenting with gradual progression of rotational vertigo, gait ataxia and vertical diplopia, continuously progressing for 6 months and 6 years, respectively. Autoimmune laboratory examinations showed remarkably increased serum and CSF GAD-ab levels. Their medical histories revealed late-onset type 1 diabetes mellitus (T1DM) and other concomitant autoimmune disorders (Grave's disease, Hashimoto's thyroiditis). Cerebral MRI and laboratory examinations were unremarkable. The diagnosis of GAD-ab-associated cerebellar ataxia with particular brainstem involvement was established in both women. After the exclusion of an underlying malignancy, immunosuppressive therapy has been initiated in both patients, which resulted in stabilization in one and in clinical improvement in the other patient.", + "summary_subclaims": [ + "The patients were 2 female siblings.", + "The patients were aged 74 and 76 years.", + "They presented with gradual progression of rotational vertigo.", + "They presented with gait ataxia.", + "They presented with vertical diplopia.", + "The symptoms had been continuously progressing for 6 months and 6 years, respectively.", + "Autoimmune laboratory examinations showed remarkably increased serum GAD-ab levels.", + "Autoimmune laboratory examinations showed remarkably increased CSF GAD-ab levels.", + "Their medical histories revealed late-onset type 1 diabetes mellitus.", + "Their medical histories revealed other concomitant autoimmune disorders.", + "Cerebral MRI and laboratory examinations were unremarkable.", + "The diagnosis of GAD-ab-associated cerebellar ataxia with particular brainstem involvement was established in both women.", + "An underlying malignancy was excluded.", + "Immunosuppressive therapy has been initiated in both patients.", + "Immunosuppressive therapy resulted in stabilization in one patient.", + "Immunosuppressive therapy resulted in clinical improvement in the other patient." + ] + }, + { + "id": "multiclinsum_test_2230_en.txt", + "fulltext": "We report a case of a 35-year-old male diagnosed with trigeminal neuralgia eight months prior who presented with two days of intractable 10/10 left facial pain with radiation from his jaw to his temple. This pain was exacerbated by clenching of his jaw and chewing. He described his pain as sharp and shooting, lasting only seconds, and consistently self-resolving. Over the two days prior to his ED visit, he had more frequent episodes of pain, and endorsed up to 30 episodes a day. His pain was refractory to multiple over-the-counter pain medications. The day of presentation he had six hours of near-constant clusters of severe shooting pain. His physical exam revealed normal vital signs, normal head, eyes, ears, nose, and throat exam except for hyperalgesia of his left face. Cranial nerves 2–12 were intact. He had normal speech, symmetric motor and sensation to all four extremities, and a normal gait. He had no meningismus upon examination of his neck.\nIn our ED, he was initially treated with a cocktail of ibuprofen, diphenhydramine, prochlorperazine, and one liter of normal saline. The patient had no resolution of symptoms 45 minutes after administration of this “migrane cocktail.” The history and physical exam were consistent with a trigeminal neuralgia crisis. To treat the patient’s neuropathic pain, he was given 250 milligrams (mg) of fosphenytoin that was infused intravenously (IV) over 10 minutes. At the end of the infusion, his pain had completely resolved. He was discharged with a neurology follow-up and a prescription for carbamazepine. Chart review six months after the patient was discharged did not show any other ED visits listed after discharge.", + "fulltext_subclaims": [ + "The patient is a 35-year-old male.", + "The patient was diagnosed with trigeminal neuralgia eight months prior.", + "The patient had two days of intractable 10/10 left facial pain.", + "The pain radiated from his jaw to his temple.", + "The pain was exacerbated by clenching of his jaw.", + "The pain was described as sharp and shooting.", + "The pain lasted only seconds.", + "The pain was consistently self-resolving.", + "The patient had more frequent episodes of pain over the two days prior to his ED visit.", + "The patient endorsed up to 30 episodes of pain a day.", + "The pain was refractory to multiple over-the-counter pain medications.", + "The patient had six hours of near-constant clusters of severe shooting pain on the day of presentation.", + "The physical exam revealed normal vital signs.", + "The head, eyes, ears, nose, and throat exam was normal except for hyperalgesia of his left face.", + "Cranial nerves 2–12 were intact.", + "The patient had normal speech.", + "The patient had symmetric motor and sensation to all four extremities.", + "The patient had a normal gait.", + "The patient had no meningismus upon examination of his neck.", + "In the ED, the patient was initially treated with a cocktail of ibuprofen, diphenhydramine, prochlorperazine, and one liter of normal saline.", + "The patient had no resolution of symptoms 45 minutes after administration of the cocktail.", + "The history and physical exam were consistent with a trigeminal neuralgia crisis.", + "The patient was given 250 milligrams of fosphenytoin that was infused intravenously over 10 minutes.", + "At the end of the infusion, the patient's pain had completely resolved.", + "The patient was discharged with a neurology follow-up.", + "The patient was discharged with a prescription for carbamazepine.", + "Chart review six months after discharge did not show any other ED visits listed after discharge." + ], + "summary": "This is a case of a 35-year-old male diagnosed with trigeminal neuralgia who presented with acute facial pain. His history and physical exam were consistent with an acute exacerbation of his trigeminal neuralgia. The patient was refractory to multiple doses of standard pain medication in the ED, and the decision was made to attempt IV fosphenytoin to relieve his pain. He was given 250 milligrams of fosphenytoin that was infused via IV over 10 minutes. By the end of the infusion, the patient had reported complete resolution of his pain.", + "summary_subclaims": [ + "This is a case of a 35-year-old male diagnosed with trigeminal neuralgia.", + "He presented with acute facial pain.", + "His history and physical exam were consistent with an acute exacerbation of his trigeminal neuralgia.", + "The patient was refractory to multiple doses of standard pain medication in the ED.", + "The decision was made to attempt IV fosphenytoin to relieve his pain.", + "He was given 250 milligrams of fosphenytoin that was infused via IV over 10 minutes.", + "By the end of the infusion, the patient had reported complete resolution of his pain." + ] + }, + { + "id": "multiclinsum_test_1531_en.txt", + "fulltext": "A 36-year-old African American female with significant medical history of obesity and hypertension presented to the emergency department with headache, altered level of consciousness, fever, and severe neck stiffness. The patient was previously evaluated by multiple providers in the emergency department (urgent care) and was diagnosed with chronic allergic sinusitis. She was prescribed multiple courses of antibiotics with supportive care and sent home. She had recent animal exposure to a stray cat and consumed deli meats regularly. There was no history of recent travel. She denied any mosquito or tick bites.\nOn physical exam, the patient was febrile, tachycardic, tachypneic, and disoriented to place and time with inappropriate responses to questioning, and nuchal rigidity was present. Complete blood cell count revealed a white blood cell count of 16.88 × 109 per liter with 80% band forms and 14% segmented neutrophils. Comprehensive metabolic panel showed no electrolyte abnormalities or renal or liver dysfunction. Urine analysis was within normal limits. CSF analysis revealed WBC count of 7810 cells/μL with 83% neutrophils, red blood cells count of 22 cells/μL, protein of 267 mg/dL, and glucose of 27 mg/100 mL. Gram stain, West Nile Virus antibody titer, and Coccidioides antibody were negative. Serum lactate was within normal limits. Unfortunately, the patient had received intravenous (IV) antibiotics prior to lumbar puncture and the CSF cultures remained negative. The CSF was not sent for detection of bacterial antigens.\nDespite the negative gram stain and cultures of the CSF, the clinical presentation and results of lumbar puncture were consistent with bacterial meningitis. In the emergency department, the patient was started on broad-spectrum antibiotics and antivirals with vancomycin, piperacillin/tazobactam, and acyclovir. On the medicine service, antibiotics and antivirals were transitioned to standard therapy for bacterial meningitis with ceftriaxone and vancomycin. The patient had resolution in her altered level of consciousness by the following day and was able to answer questions.\nUpon further questioning, she endorsed persistent unilateral clear nasal drainage lasting months and postural headache that was worse when standing or sitting and relieved by laying down. At this time, there was high clinical suspicion of CSF rhinorrhea. Computerized tomography (CT) scan of the sinuses initially indicated findings consistent with chronic sinusitis. However, the patient continued to have copious unilateral clear nasal discharge. Magnetic resonance imaging (MRI) of the orbits was completed which showed findings consistent with CSF rhinorrhea and bony defect of the basal skull . Additionally, her nasal discharge was positive for beta-2 transferrin. Otolaryngology was consulted for further evaluation. The patient was taken to surgery and intraoperative findings were consistent with CSF rhinorrhea of the left sphenoid sinus. The mucosal defect was repaired with free septal mucosal graft and tissue seal. The patient recovered without complications and was discharged home to complete a course of IV antibiotics.", + "fulltext_subclaims": [ + "The patient is a 36-year-old African American female.", + "The patient has a medical history of obesity.", + "The patient has a medical history of hypertension.", + "The patient presented with headache.", + "The patient presented with altered level of consciousness.", + "The patient presented with fever.", + "The patient presented with severe neck stiffness.", + "The patient was previously diagnosed with chronic allergic sinusitis.", + "The patient was prescribed multiple courses of antibiotics.", + "The patient had recent animal exposure to a stray cat.", + "The patient consumed deli meats regularly.", + "The patient denied any mosquito or tick bites.", + "On physical exam, the patient was febrile.", + "On physical exam, the patient was tachycardic.", + "On physical exam, the patient was tachypneic.", + "On physical exam, the patient was disoriented to place and time.", + "On physical exam, nuchal rigidity was present.", + "Complete blood cell count revealed a white blood cell count of 16.88 × 109 per liter.", + "CSF analysis revealed WBC count of 7810 cells/μL.", + "CSF analysis showed 83% neutrophils.", + "CSF analysis showed protein of 267 mg/dL.", + "CSF analysis showed glucose of 27 mg/100 mL.", + "Gram stain of CSF was negative.", + "The patient had received intravenous antibiotics prior to lumbar puncture.", + "CSF cultures remained negative.", + "The clinical presentation and results of lumbar puncture were consistent with bacterial meningitis.", + "The patient was started on vancomycin.", + "The patient was started on piperacillin/tazobactam.", + "The patient was started on acyclovir.", + "The patient had resolution in her altered level of consciousness by the following day.", + "The patient endorsed persistent unilateral clear nasal drainage lasting months.", + "The patient had postural headache that was worse when standing or sitting.", + "The patient's nasal discharge was positive for beta-2 transferrin.", + "Magnetic resonance imaging showed findings consistent with CSF rhinorrhea.", + "Magnetic resonance imaging showed bony defect of the basal skull.", + "Otolaryngology was consulted for further evaluation.", + "The patient was taken to surgery.", + "Intraoperative findings were consistent with CSF rhinorrhea of the left sphenoid sinus.", + "The mucosal defect was repaired with free septal mucosal graft and tissue seal.", + "The patient recovered without complications.", + "The patient was discharged home." + ], + "summary": "A 36-year-old African American female with significant medical history of obesity and hypertension presented to the emergency department with headache, altered level of consciousness, fever, and neck stiffness. Previously, the patient was diagnosed with chronic allergic sinusitis by multiple providers. Physical exam findings and laboratory tests were consistent with bacterial meningitis. The patient was admitted and started on appropriate antibiotic therapy. The patient continued to complain of persistent unilateral clear nasal drainage. The initial report from the computerized tomography scan of the sinuses indicated findings consistent with chronic sinusitis. Magnetic resonance imaging of the orbits revealed findings consistent with CSF rhinorrhea. Otolaryngology was consulted for surgical intervention.", + "summary_subclaims": [ + "The patient is a 36-year-old African American female.", + "The patient has a medical history of obesity.", + "The patient has a medical history of hypertension.", + "The patient presented with headache.", + "The patient presented with altered level of consciousness.", + "The patient presented with fever.", + "The patient presented with neck stiffness.", + "The patient was previously diagnosed with chronic allergic sinusitis by multiple providers.", + "Physical exam findings and laboratory tests were consistent with bacterial meningitis.", + "The patient was admitted and started on appropriate antibiotic therapy.", + "The patient continued to complain of persistent unilateral clear nasal drainage.", + "The initial report from the computerized tomography scan of the sinuses indicated findings consistent with chronic sinusitis.", + "Magnetic resonance imaging of the orbits revealed findings consistent with CSF rhinorrhea.", + "Otolaryngology was consulted for surgical intervention." + ] + }, + { + "id": "multiclinsum_test_3382_en.txt", + "fulltext": "A 30-year-old man was admitted to our hospital on June 6, 2020, presenting with abdominal distension that had developed over the preceding 2 weeks. Initially, the patient noted abdominal distension without any accompanying symptoms such as pain, diarrhea, nausea, vomiting, or fever and, thus, did not seek immediate medical attention. As the distension worsened, he sought evaluation at our outpatient department. An abdominal ultrasound revealed ascites, leading to his admission.\n\nOn physical examination, the patient’s temperature was 38.2 °C, with clear consciousness and overall good condition. Heart and lung examinations revealed no abnormalities. Abdominal examination showed distension with slight tenderness in the right lower quadrant, positive moving dullness, and no muscle rigidity or rebound tenderness.\n\nThe differential diagnosis included tuberculous peritonitis, purulent peritonitis, and cirrhosis-associated ascites. Laboratory tests at admission revealed the following.\n\nComplete blood count: White blood cell count of 11.7 × 109/L, neutrophil percentage of 83.2%, lymphocyte percentage of 11.7%, hemoglobin of 162 g/L, and platelet count of 423 × 109/L.\n\nBiochemistry: Alanine aminotransferase of 40.0 U/L, aspartate aminotransferase of 33.0 U/L, phosphocreatine kinase of 60.0 U/L, albumin of 39.8 g/L, glutamyl transpeptidase of 16.0 U/L, total bilirubin of 6.4 µmol/L, direct bilirubin of 1.7 µmol/L, C-reactive protein of 10.2 mg/L, and procalcitonin of 0.077 ng/L.\n\nInfection screenings for hepatitis B virus, hepatitis C virus, human immunodeficiency virus, and syphilis were negative. Liver stiffness testing was normal. Abdominal computed tomography (CT) showed thickening of the small intestine and ileocecal wall, disorganization of intestinal structure, thickening of the greater omentum, and an increased number of lymph nodes in the abdominal cavity, suggesting peritonitis.\n\nDiagnostic procedures and initial management\nAn abdominal puncture was performed, yielding turbid ascitic fluid with a leukocyte count of 139 × 109/L, predominantly multinucleated cells (98%). Biochemical analysis of the ascitic fluid revealed: albumin of 33.0 g/L, lactate dehydrogenase of 3554.0 U/L, total protein of 48.8 g/L, glucose of 0.07 mmol/L, chloride of 105.6 mmol/L, and adenosine deaminase of 39.5 U/L. Interferon levels in ascitic fluid were normal, and cultures were negative. The initial diagnosis was suppurative peritonitis. Treatment with cefotaxime and sulbactam (4.5 g, intravenous drip, twice a day) was initiated to target common gram-negative bacilli of intestinal origin.\n\nFurther evaluations, including purified protein derivative and T-spot tuberculosis tests, were negative, and normal interferon levels in ascitic fluid did not support tuberculous peritonitis. Continued investigation revealed ileocecal lesions that were suspected to cause purulent peritonitis. The gastrointestinal surgeon noted the presence of lesions in the ileocecal area and potential appendix perforation but recommended against surgery. Instead, they advised continued antibacterial therapy.\n\nDespite the addition of etimicin (0.3 g, intravenous drip, once a day) on June 15, the patient’s condition did not improve. The antibiotic regimen was adjusted to imipenem and cilastatin sodium (2.0 g, intravenous drip, once every 8 hours) on the same date. While the patient’s fever resolved, ascites persisted. Nutritional support was provided, and additional ascitic fluid analyses were performed, consistently showing no tumor cells or evidence of tuberculosis. The patient and his family chose to discharge him against medical advice on June 22.\n\nAfter discharge, the patient continued to experience ascites and fever but did not seek further treatment. Despite recommendations for further evaluation at a larger facility, the patient refused additional care. On August 24, 2020, he was readmitted to Nanjing First Hospital. A repeat abdominal CT showed multiple enlarged lymph nodes in the abdomen, raising suspicion of a hematological malignancy. Bone marrow aspiration confirmed the diagnosis of ALL.\n\nDifferential diagnosis\n\nTuberculous peritonitis\nThe patient, a young male with fever and ascites, underwent several tests to rule out tuberculous peritonitis. Acid-fast staining of the ascitic fluid was negative, and the concentration of interferon-γ in the ascitic fluid was not elevated. In addition, the peripheral blood T-spot tuberculosis test was negative. These findings collectively excluded tuberculous peritonitis.\n\nPurulent peritonitis\nThe patient presented with fever and ascites. Routine analysis of the ascitic fluid revealed a significant increase in white blood cells and a predominance of neutrophils. Although bacterial cultures were inconclusive, the patient’s fever subsided and the white blood cell count in the ascitic fluid decreased following antibacterial treatment. These clinical responses support the diagnosis of purulent peritonitis.\n\nCirrhosis-associated ascites\nThe patient, a young male, underwent liver stiffness measurement using fibro touch, which indicated normal liver hardness. In addition, abdominal CT did not show signs of cirrhosis. Therefore, cirrhosis-associated ascites was excluded.\n\nOutcome and follow-up\nThe patient was admitted to the hematology department for further treatment. Unfortunately, despite intervention, the patient’s condition deteriorated, and he eventually passed away.", + "fulltext_subclaims": [ + "The patient was admitted on June 6, 2020.", + "The patient had abdominal distension that had developed over the preceding 2 weeks.", + "The patient did not seek immediate medical attention.", + "An abdominal ultrasound revealed ascites.", + "The patient’s temperature was 38.2 °C.", + "Abdominal examination showed distension with slight tenderness in the right lower quadrant.", + "The differential diagnosis included tuberculous peritonitis.", + "The differential diagnosis included purulent peritonitis.", + "The differential diagnosis included cirrhosis-associated ascites.", + "White blood cell count was 11.7 × 109/L.", + "Neutrophil percentage was 83.2%.", + "Lymphocyte percentage was 11.7%.", + "Hemoglobin was 162 g/L.", + "Platelet count was 423 × 109/L.", + "Alanine aminotransferase was 40.0 U/L.", + "Aspartate aminotransferase was 33.0 U/L.", + "Phosphocreatine kinase was 60.0 U/L.", + "Albumin was 39.8 g/L.", + "Glutamyl transpeptidase was 16.0 U/L.", + "Total bilirubin was 6.4 µmol/L.", + "Direct bilirubin was 1.7 µmol/L.", + "C-reactive protein was 10.2 mg/L.", + "Procalcitonin was 0.077 ng/L.", + "Infection screenings for hepatitis B virus, hepatitis C virus, human immunodeficiency virus, and syphilis were negative.", + "Liver stiffness testing was normal.", + "Abdominal CT showed thickening of the small intestine and ileocecal wall.", + "Abdominal CT showed thickening of the greater omentum.", + "Abdominal CT showed an increased number of lymph nodes in the abdominal cavity.", + "An abdominal puncture was performed.", + "Ascitic fluid was turbid.", + "Ascitic fluid leukocyte count was 139 × 109/L.", + "Ascitic fluid leukocytes were predominantly multinucleated cells (98%).", + "Ascitic fluid albumin was 33.0 g/L.", + "Ascitic fluid lactate dehydrogenase was 3554.0 U/L.", + "Ascitic fluid total protein was 48.8 g/L.", + "Ascitic fluid glucose was 0.07 mmol/L.", + "Ascitic fluid chloride was 105.6 mmol/L.", + "Ascitic fluid adenosine deaminase was 39.5 U/L.", + "Interferon levels in ascitic fluid were normal.", + "Cultures of ascitic fluid were negative.", + "The initial diagnosis was suppurative peritonitis.", + "Treatment with cefotaxime and sulbactam was initiated.", + "The antibiotic regimen was adjusted to imipenem and cilastatin sodium on June 15.", + "The patient’s fever resolved.", + "Ascites persisted.", + "Additional ascitic fluid analyses showed no tumor cells.", + "Additional ascitic fluid analyses showed no evidence of tuberculosis.", + "The patient was discharged against medical advice on June 22.", + "The patient continued to experience ascites after discharge.", + "The patient continued to experience fever after discharge.", + "The patient was readmitted to Nanjing First Hospital on August 24, 2020.", + "A repeat abdominal CT showed multiple enlarged lymph nodes in the abdomen.", + "Bone marrow aspiration confirmed the diagnosis of ALL.", + "Acid-fast staining of the ascitic fluid was negative.", + "The concentration of interferon-γ in the ascitic fluid was not elevated.", + "The peripheral blood T-spot tuberculosis test was negative.", + "These findings collectively excluded tuberculous peritonitis.", + "The patient presented with fever and ascites.", + "Routine analysis of the ascitic fluid revealed a significant increase in white blood cells.", + "Routine analysis of the ascitic fluid revealed a predominance of neutrophils.", + "The patient’s fever subsided following antibacterial treatment.", + "The white blood cell count in the ascitic fluid decreased following antibacterial treatment.", + "These clinical responses support the diagnosis of purulent peritonitis.", + "Liver stiffness measurement indicated normal liver hardness.", + "Abdominal CT did not show signs of cirrhosis.", + "Cirrhosis-associated ascites was excluded.", + "The patient was admitted to the hematology department.", + "The patient’s condition deteriorated.", + "The patient eventually passed away." + ], + "summary": "Patient concerns: A 30-year-old male was admitted to the hospital with the primary complaint of ascites.\n\nDiagnosis: ALL.\n\nInterventions: The patient was initially diagnosed with suppurative peritonitis through abdominal puncture. The abdominal computed tomography scan revealed ileocecal lesions, which were thought to be the source of the purulent peritonitis. Despite receiving antibacterial therapy and undergoing peritoneal effusion drainage, the treatment proved ineffective. The patient chose to discontinue hospitalization and was discharged on June 22. On August 24, he was readmitted to Nanjing First Hospital. A follow-up abdominal computed tomography scan revealed multiple enlarged lymph nodes in the abdomen, raising suspicion of a hematological malignancy. Bone marrow cytology subsequently confirmed the diagnosis of ALL.\n\nOutcomes: The patient was admitted to the hematology department for further treatment. Unfortunately, despite intervention, the patient passed away.", + "summary_subclaims": [ + "The patient is a 30-year-old male.", + "The patient was admitted to the hospital with the primary complaint of ascites.", + "The patient was initially diagnosed with suppurative peritonitis through abdominal puncture.", + "The abdominal computed tomography scan revealed ileocecal lesions.", + "The ileocecal lesions were thought to be the source of the purulent peritonitis.", + "The patient received antibacterial therapy.", + "The patient underwent peritoneal effusion drainage.", + "The treatment proved ineffective.", + "The patient chose to discontinue hospitalization.", + "The patient was discharged on June 22.", + "The patient was readmitted to Nanjing First Hospital on August 24.", + "A follow-up abdominal computed tomography scan revealed multiple enlarged lymph nodes in the abdomen.", + "The multiple enlarged lymph nodes raised suspicion of a hematological malignancy.", + "Bone marrow cytology confirmed the diagnosis of ALL.", + "The patient was admitted to the hematology department for further treatment.", + "The patient passed away." + ] + }, + { + "id": "multiclinsum_test_611_en.txt", + "fulltext": "A 59-year-old Pakistani woman with a past medical history of hypertension and a significant family history of cancer in first-degree relatives (breast, ovarian, and pancreatic cancer) was referred to the cardiothoracic surgery clinic. This was due to an incidental finding of a nodular density on her chest X-ray as part of a preoperative workup for a total left knee replacement due to osteoarthritis. However, there were no previous chest images for comparison. Aside from a minor complaint of blood-tinged sputum in the morning, there were no complaints or symptoms. She was vitally stable and saturating well on room air. Her general physical, cardiovascular, respiratory, abdominal, and central nervous system examinations were unremarkable.\nRadiological imaging (CXR) showed a nodular density in the right lower zone of the right lung measuring approximately 2.5 cm × 2 cm. A subsequently conducted high definition [18F]fluorodeoxyglucose (FDG) positron emission tomography/computed tomography (PET/CT) scan revealed a lobulated soft-tissue lesion measuring 23 mm × 23 mm (with internal cavitation) along the medial aspect of the anterior segment of the lower lobe of the right lung . The lesion had a maximum standardized uptake value (SUVmax) of 2.7. No evidence of hypermetabolic nodal, pulmonary, hepatic, splenic, adrenal, or bony metastasis was observed.\nA CT-guided core biopsy of the lesion was performed. Histopathological evaluation revealed a core of a spindle cell lesion with smaller cores of native unremarkable lung parenchyma. Significant cytological atypia or increased mitotic activity was not seen. Immunohistochemical staining revealed the cells to be S100 focal positive, SOX-10 negative, ASMA negative, Melan A negative, HMB-45 negative, STAT6 negative, and CD34 patchy positive. A diagnosis of a benign spindle cell lesion, likely of neural origin, was made. An elective surgical resection was planned for a month later.\nAfter standard preoperative optimization and preparation, a posterolateral thoracotomy with right lower lobectomy was performed under general anesthesia. The pleural cavity was entered through the fifth intercostal space. Enlarged station 9R and 10R lymph nodes and a mass in the lower lobe of the right lung were visualized, while no masses were observed in the middle or upper lobes. There were no pleural nodules or pleural effusion. The inferior pulmonary ligament was divided, and the inferior pulmonary vein was identified and divided between ties. The oblique fissure was incomplete, and was used to separate the upper, middle, and lower lobes of the lung through cautery. The pulmonary artery was identified at the confluence of the oblique and horizontal fissures, and the superior segmental and basilar branches were visualized. The superior segmental branch and the pulmonary artery distal to the take-off of the middle lobe branch were both divided between ties. The bronchus intermedius was dissected and the middle lobe bronchus was identified. The bronchus distal to the middle lobe take-off was dissected, and a TA-30 stapler was used to divide the superior segmental bronchus and the bronchus distal to the middle lobe take-off. The mass was then resected, and hemostasis was secured. The surgical wound was closed in layers after the placement of an extrapleural catheter and chest tubes, and the patient was shifted to the in-patient facility. The patient remained vitally and hemodynamically stable and was discharged 3 days after the operation. The patient was confirmed to be in her usual state of health upon 6-month and 1-year follow-up, with no late complications or recurrences.\nHistopathological examination of the resected lobe showed lung parenchyma infiltrated by an encapsulated neoplastic lesion composed of well-differentiated Schwann cells. The neoplastic cells showed a biphasic pattern with compact areas of spindle cells having moderate eosinophilic cytoplasm and normal chromatic elongated nuclei. Areas of occasional palisading (Verocay bodies) were also seen . These morphological findings, combined with immunohistochemical staining results concurrent with those mentioned earlier, were consistent with the diagnosis of an intrapulmonary schwannoma.", + "fulltext_subclaims": [ + "The patient is a 59-year-old Pakistani woman.", + "She has a past medical history of hypertension.", + "She has a significant family history of cancer in first-degree relatives.", + "The family history includes breast, ovarian, and pancreatic cancer.", + "She was referred to the cardiothoracic surgery clinic.", + "The referral was due to an incidental finding of a nodular density on her chest X-ray.", + "The chest X-ray was part of a preoperative workup for a total left knee replacement.", + "The knee replacement was due to osteoarthritis.", + "There were no previous chest images for comparison.", + "She had a minor complaint of blood-tinged sputum in the morning.", + "She was vitally stable.", + "She was saturating well on room air.", + "Her general physical examination was unremarkable.", + "Her cardiovascular examination was unremarkable.", + "Her respiratory examination was unremarkable.", + "Her abdominal examination was unremarkable.", + "Her central nervous system examination was unremarkable.", + "Radiological imaging showed a nodular density in the right lower zone of the right lung.", + "The nodular density measured approximately 2.5 cm × 2 cm.", + "A high definition [18F]fluorodeoxyglucose (FDG) PET/CT scan was conducted.", + "The PET/CT scan revealed a lobulated soft-tissue lesion measuring 23 mm × 23 mm.", + "The lesion had internal cavitation.", + "The lesion was located along the medial aspect of the anterior segment of the lower lobe of the right lung.", + "The lesion had a maximum standardized uptake value (SUVmax) of 2.7.", + "No evidence of hypermetabolic nodal metastasis was observed.", + "No evidence of hypermetabolic pulmonary metastasis was observed.", + "No evidence of hypermetabolic hepatic metastasis was observed.", + "No evidence of hypermetabolic splenic metastasis was observed.", + "No evidence of hypermetabolic adrenal metastasis was observed.", + "No evidence of hypermetabolic bony metastasis was observed.", + "A CT-guided core biopsy of the lesion was performed.", + "Histopathological evaluation revealed a core of a spindle cell lesion.", + "The core biopsy also showed smaller cores of native unremarkable lung parenchyma.", + "Significant cytological atypia was not seen.", + "Increased mitotic activity was not seen.", + "Immunohistochemical staining revealed the cells to be S100 focal positive.", + "Immunohistochemical staining revealed the cells to be SOX-10 negative.", + "Immunohistochemical staining revealed the cells to be ASMA negative.", + "Immunohistochemical staining revealed the cells to be Melan A negative.", + "Immunohistochemical staining revealed the cells to be HMB-45 negative.", + "Immunohistochemical staining revealed the cells to be STAT6 negative.", + "Immunohistochemical staining revealed the cells to be CD34 patchy positive.", + "A diagnosis of a benign spindle cell lesion was made.", + "The diagnosis was likely of neural origin.", + "An elective surgical resection was planned for a month later.", + "A posterolateral thoracotomy with right lower lobectomy was performed.", + "The operation was performed under general anesthesia.", + "The pleural cavity was entered through the fifth intercostal space.", + "Enlarged station 9R and 10R lymph nodes were visualized.", + "A mass in the lower lobe of the right lung was visualized.", + "No masses were observed in the middle or upper lobes.", + "No pleural nodules were observed.", + "No pleural effusion was observed.", + "The inferior pulmonary ligament was divided.", + "The inferior pulmonary vein was identified and divided between ties.", + "The oblique fissure was incomplete.", + "The oblique fissure was used to separate the upper, middle, and lower lobes of the lung through cautery.", + "The pulmonary artery was identified at the confluence of the oblique and horizontal fissures.", + "The superior segmental and basilar branches were visualized.", + "The superior segmental branch and the pulmonary artery distal to the take-off of the middle lobe branch were both divided between ties.", + "The bronchus intermedius was dissected.", + "The middle lobe bronchus was identified.", + "The bronchus distal to the middle lobe take-off was dissected.", + "A TA-30 stapler was used to divide the superior segmental bronchus and the bronchus distal to the middle lobe take-off.", + "The mass was then resected.", + "Hemostasis was secured.", + "The surgical wound was closed in layers after the placement of an extrapleural catheter and chest tubes.", + "The patient was shifted to the in-patient facility.", + "The patient remained vitally and hemodynamically stable.", + "The patient was discharged 3 days after the operation.", + "The patient was confirmed to be in her usual state of health upon 6-month follow-up.", + "The patient was confirmed to be in her usual state of health upon 1-year follow-up.", + "No late complications were observed.", + "No recurrences were observed.", + "Histopathological examination of the resected lobe showed lung parenchyma infiltrated by an encapsulated neoplastic lesion composed of well-differentiated Schwann cells.", + "The neoplastic cells showed a biphasic pattern with compact areas of spindle cells having moderate eosinophilic cytoplasm and normal chromatic elongated nuclei.", + "Areas of occasional palisading (Verocay bodies) were also seen.", + "The morphological findings, combined with immunohistochemical staining results, were consistent with the diagnosis of an intrapulmonary schwannoma." + ], + "summary": "In this article, we report an incidental finding of an intrapulmonary schwannoma in a 59-year-old Pakistani woman who was grossly asymptomatic upon presentation to the cardiothoracic surgery clinic. An", + "summary_subclaims": [ + "The article reports an incidental finding of an intrapulmonary schwannoma.", + "The patient was a 59-year-old Pakistani woman.", + "The patient was grossly asymptomatic upon presentation.", + "The patient presented to the cardiothoracic surgery clinic." + ] + }, + { + "id": "multiclinsum_test_1119_en.txt", + "fulltext": "A 75-year-old man was diagnosed with gastric cancer through a medical check-up and was referred to our department. The patient had no subjective symptoms or remarkable past medical history. The tumor marker carbohydrate antigen 19-9 (CA19-9) was elevated, with a value of 231.5 U/ml . Upper endoscopy demonstrated a 5-cm circumferential ulcerated lesion at the cardia . Biopsy showed a poorly differentiated tubular adenocarcinoma. Computed tomography (CT) showed a wall thickening of the lesser curvature side of the upper gastric body . The patient underwent laparoscopic total gastrectomy with lymph node dissection, and the pathological diagnosis was consistent with a moderately differentiated tubular adenocarcinoma, pathological stage T4aN1M0, and IIIA according to the UICC classification . The postoperative course was unremarkable, and the patient was discharged. He refused adjuvant chemotherapy and was under close observation. The patient was regularly followed up with laboratory tests and imaging studies. Twenty-three months after the primary gastrectomy, a CT scan revealed an irregular mass near the port site wounds . The mass continued growing over time, and port site recurrence was suspected. The CA19-9 level increased to 142.2 U/ml . The patient underwent mass resection, and the pathological diagnosis was consistent with metastatic adenocarcinoma in the subcutaneous tissue at the port site . In the operative findings, there were no ascites and disseminated nodules in the abdominal cavity. Macroscopic findings of the resected specimen revealed that the center of the tumor was not in the peritoneum, but the abdominal wall. Therefore, it was considered to be a PSM rather than peritoneal dissemination. Thirteen months after the second surgery, CT revealed an enhanced mass in the abdominal wall. Furthermore, PET-CT showed an elevated uptake in the rectus abdominis muscle and a SUV of 3.1 . Fine-needle aspiration biopsy of the lesion detected malignant cells with suspected metastatic adenocarcinoma. The CA19-9 level was elevated to 53.6 U/ml again . The patient underwent mass resection again. The mass had macroscopically infiltrated into the rectus abdominis muscle . Similar to the first recurrence, there were no ascites or disseminated nodules in the abdominal cavity. The pathological diagnosis was identical to that of a gastric metastatic adenocarcinoma in the rectus abdominis muscle . After thirty-five months from the third surgery, CT revealed a mass in the left gluteal region. PET-CT revealed a 35-mm mass in the lateral subcutaneous area of the left iliocostalis lumborum muscle, which showed an elevated SUV of 9.6 . Percutaneous biopsy of the lesion revealed a metastatic adenocarcinoma, and the CA19-9 level was 111 U/ml . Another mass resection procedure was performed, and the pathological diagnosis was consistent with subcutaneous metastasis from the gastric adenocarcinoma . Since tumor cells were present at the resection margin, additional radiation therapy was performed. After each recurrence, the patient did not undergo adjuvant chemotherapy. The patient has survived 78 months after primary gastrectomy.", + "fulltext_subclaims": [ + "A 75-year-old man was diagnosed with gastric cancer through a medical check-up.", + "The patient had no subjective symptoms.", + "The tumor marker carbohydrate antigen 19-9 (CA19-9) was elevated, with a value of 231.5 U/ml.", + "Upper endoscopy demonstrated a 5-cm circumferential ulcerated lesion at the cardia.", + "Biopsy showed a poorly differentiated tubular adenocarcinoma.", + "Computed tomography (CT) showed a wall thickening of the lesser curvature side of the upper gastric body.", + "The patient underwent laparoscopic total gastrectomy with lymph node dissection.", + "The pathological diagnosis was consistent with a moderately differentiated tubular adenocarcinoma.", + "The pathological stage was T4aN1M0.", + "The stage was IIIA according to the UICC classification.", + "The postoperative course was unremarkable.", + "The patient was discharged.", + "He refused adjuvant chemotherapy.", + "Twenty-three months after the primary gastrectomy, a CT scan revealed an irregular mass near the port site wounds.", + "The mass continued growing over time.", + "Port site recurrence was suspected.", + "The CA19-9 level increased to 142.2 U/ml.", + "The patient underwent mass resection.", + "The pathological diagnosis was consistent with metastatic adenocarcinoma in the subcutaneous tissue at the port site.", + "In the operative findings, there were no ascites.", + "There were no disseminated nodules in the abdominal cavity.", + "The center of the tumor was not in the peritoneum.", + "The center of the tumor was in the abdominal wall.", + "It was considered to be a PSM rather than peritoneal dissemination.", + "Thirteen months after the second surgery, CT revealed an enhanced mass in the abdominal wall.", + "PET-CT showed an elevated uptake in the rectus abdominis muscle.", + "The SUV was 3.1.", + "Fine-needle aspiration biopsy of the lesion detected malignant cells with suspected metastatic adenocarcinoma.", + "The CA19-9 level was elevated to 53.6 U/ml again.", + "The patient underwent mass resection again.", + "The mass had macroscopically infiltrated into the rectus abdominis muscle.", + "There were no ascites or disseminated nodules in the abdominal cavity.", + "The pathological diagnosis was identical to that of a gastric metastatic adenocarcinoma in the rectus abdominis muscle.", + "After thirty-five months from the third surgery, CT revealed a mass in the left gluteal region.", + "PET-CT revealed a 35-mm mass in the lateral subcutaneous area of the left iliocostalis lumborum muscle.", + "The mass showed an elevated SUV of 9.6.", + "Percutaneous biopsy of the lesion revealed a metastatic adenocarcinoma.", + "The CA19-9 level was 111 U/ml.", + "Another mass resection procedure was performed.", + "The pathological diagnosis was consistent with subcutaneous metastasis from the gastric adenocarcinoma.", + "Tumor cells were present at the resection margin.", + "Additional radiation therapy was performed.", + "After each recurrence, the patient did not undergo adjuvant chemotherapy.", + "The patient has survived 78 months after primary gastrectomy." + ], + "summary": "A 75-year-old man was diagnosed with gastric cancer and referred to our department. Upper endoscopy demonstrated a 5-cm circumferential ulcerated lesion at the cardia. Biopsy findings showed a poorly differentiated tubular adenocarcinoma. He underwent laparoscopic total gastrectomy with lymph node dissection, and pathologic examination revealed a moderately differentiated tubular adenocarcinoma stage T4aN1M0 and IIIA according to the UICC (Union for International Cancer Control) classification. He refused adjuvant chemotherapy and was only carefully observed. Twenty-three months after the primary gastrectomy, computed tomography (CT) revealed an irregular mass near the port site wounds. Then the patient underwent mass resection, and the pathological diagnosis was consistent with metastatic adenocarcinoma, located in the subcutaneous tissue at the port site wounds. Thirteen months after the second surgery, CT revealed an enhanced mass in the abdominal wall. Positron emission tomography (PET) CT showed an elevated uptake in the rectus abdominis muscle and a standardized uptake value (SUV) of 3.1. The patient underwent another mass resection, and the pathological diagnosis was consistent with metastatic adenocarcinoma in the rectus abdominis muscle. Thirty-five months after the third surgery, CT revealed a mass in the left gluteal subcutaneous region. Furthermore, PET-CT revealed a 35-mm mass with an elevated SUV of 9.6. Another mass resection procedure was performed, and the pathological diagnosis was consistent with metastatic adenocarcinoma in the subcutaneous tissue. Since tumor cells were present at the resection margin, additional radiation therapy was performed. The patient has survived 78 months after primary gastrectomy.", + "summary_subclaims": [ + "A 75-year-old man was diagnosed with gastric cancer.", + "Upper endoscopy demonstrated a 5-cm circumferential ulcerated lesion at the cardia.", + "Biopsy findings showed a poorly differentiated tubular adenocarcinoma.", + "He underwent laparoscopic total gastrectomy with lymph node dissection.", + "Pathologic examination revealed a moderately differentiated tubular adenocarcinoma stage T4aN1M0.", + "The stage was IIIA according to the UICC classification.", + "He refused adjuvant chemotherapy.", + "Twenty-three months after the primary gastrectomy, CT revealed an irregular mass near the port site wounds.", + "The patient underwent mass resection.", + "The pathological diagnosis was consistent with metastatic adenocarcinoma located in the subcutaneous tissue at the port site wounds.", + "Thirteen months after the second surgery, CT revealed an enhanced mass in the abdominal wall.", + "PET CT showed an elevated uptake in the rectus abdominis muscle.", + "The SUV was 3.1.", + "The patient underwent another mass resection.", + "The pathological diagnosis was consistent with metastatic adenocarcinoma in the rectus abdominis muscle.", + "Thirty-five months after the third surgery, CT revealed a mass in the left gluteal subcutaneous region.", + "PET-CT revealed a 35-mm mass with an elevated SUV of 9.6.", + "Another mass resection procedure was performed.", + "The pathological diagnosis was consistent with metastatic adenocarcinoma in the subcutaneous tissue.", + "Tumor cells were present at the resection margin.", + "Additional radiation therapy was performed.", + "The patient has survived 78 months after primary gastrectomy." + ] + }, + { + "id": "multiclinsum_test_1022_en.txt", + "fulltext": "An 82-year-old lady was referred to gynaecology outpatients in June 2007 with a one month history of post menopausal bleeding. Her past gynaecological history included a negative hysteroscopy in 1998, and previous use of hormone replacement therapy. She had previously given birth to two children. The patient was fit and well, with no significant past medical history apart from hypertension for which she took bendroflumethiazide and atenolol.\nPhysical examination revealed a bulky uterus with no adnexal masses. A pipelle biopsy demonstrated only tiny fragments of blood clot. A subsequent transvaginal ultrasound scan showed a large endometrial mass with calcification . The ovaries appeared normal. She underwent a hysteroscopy in July 2007 when a 6 cm uterine fibrotic polyp, which filled the uterine cavity, was removed.\nMicroscopy demonstrated polypoid tissue with a variably cellular and fibrotic stroma, focal adipose and possible chondroid metaplasia, but no malignant features. The glands showed focal mucinous and keratinising sqaumous epithelial metaplasia. There was focal nuclear atypia, focal mitotic activity and occasional cribriform gland fusion. These features were in keeping with either atypical complex hyperplasia within an endometrial polyp associated with metaplastic changes, or a polypoid uterine teratoma.\nImmunohistochemistry showed positive staining of the small crowded epithelium for the epithelial marker cytokeratin (CK)-7 and the thyroid and lung marker TTFI. There was positive staining of the chondroid area for S100 protein, focal staining of dilated gland epithelium and stromal cells for oestrogen receptor and progesterone receptor, and staining of stromal cells for smooth muscle α-actin (SMA). Thyroglobulin, desmin, CK20 and CDX2 staining was negative. A diagnosis of benign teratoma with thyroid gland and cartilaginous elements was therefore made.\nFollowing hysteroscopy, the bleeding continued. A repeat ultrasound scan revealed that the teratoma had grown back almost completely filling the uterine cavity. A magnetic resonance imaging (MRI) scan in November 2007 showed the tumour filling and distending the endometrial cavity and extending down into the cervix . There was evidence of posterior wall myometrial invasion but there was no lymphadenopathy and the ovaries appeared normal. Tumour markers including alpha-fetoprotein (AFP), carcinoembryonic antigen (CEA) and Ca19-9 were within normal limits. Serum Ca125 was slightly elevated at 42 U/ml (normal range 0–35 units (U)/ml) and lactate dehydrogenase (LDH) raised at 372 IU/L (normal range 125–250 U/ml).\nThe patient proceeded to a total abdominal hysterectomy and bilateral salpingo-oophorectmy in December 2007. At operation, the uterus was found to contain a haemorrhagic polypoid tumour (110 × 80 × 70 mm) arising from the posterior aspect of the endometrial cavity . Uterine size was equivalent to that of a 12-week gestation uterus.\nMicroscopically the tumour was a teratoma containing mature and immature elements with mixed malignant transformation . The tissue types found included squamous and glandular epithelium, thyroid parenchyma, smooth muscle, connective and adipose tissue. In addition there were areas of immature bone, invasive adenocarcinoma, and papillary thyroid carcinoma. There was extensive lymphovascular invasion and deep myometrial, but not serosal, involvement. The omentum, cervix, fallopian tubes and ovaries were free of tumour. Immunohistochemistry showed that the malignant epithelial components were positive for CK-7 and TTF-1, but negative for CK20 and thyroglobulin. One area of the tumour stained positive for desmin but not for SMA, S100 or CD10, suggesting that this is likely to be a small focus of myogenic sarcoma.\nThe histopathological conclusion was of a poorly differentiated adenocarcinoma and a focal myogenic sarcoma arising in a polypoid uterine teratoma with mature and immature elements. A post-operative computer tomography (CT) scan of the thorax, abdomen and pelvis found no evidence of distant disease giving an overall International Federation of Gynaecology and Obstetrics disease stage 1C.\nThe patient recovered well from surgery and was referred for oncological follow up. Given her age and performance status a surveillance approach was taken with regular clinical examinations, serial tumour markers and routine CT scans. Initially in remission, six months post-operatively para-aortic lymphadenopathy was detected on CT although she remained asymptomatic with an Eastern Cooperative Oncology Group (ECOG) performance status of 0. In view of her age and wishes for a treatment with acceptable toxicity, the patient was commenced on an initial dose of cisplatin (20 mg/m2) and etoposide (100 mg/m2). This was well tolerated so one week later treatment was continued with a fortnightly alternating regimen of paclitaxel (135 mg/m2) and etoposide (150 mg/m2), followed by paciltaxel (135 mg/m2) and cisplatin (60 mg/m2). This treatment was chosen based on our experience of its effectiveness and tolerability in the treatment of relapsed germ cell tumours and gestational trophoblastic disease [,].\nAfter three cycles of chemotherapy there was a reduction in the size of the para-aortic mass, but an increase in the cystic component suggesting possible differentiation towards a mature teratoma. Consequently she underwent a retro-peritoneal lymph node dissection in October 2008. Histology from this confirmed the presence of metastatic teratoma. Unfortunately she had a turbulent post-operative course and, although she recovered well enough to return home a month later, she sadly died shortly thereafter.", + "fulltext_subclaims": [ + "An 82-year-old lady was referred to gynaecology outpatients in June 2007 with a one month history of post menopausal bleeding.", + "Her past gynaecological history included a negative hysteroscopy in 1998.", + "She had previously given birth to two children.", + "She had hypertension for which she took bendroflumethiazide and atenolol.", + "Physical examination revealed a bulky uterus with no adnexal masses.", + "A pipelle biopsy demonstrated only tiny fragments of blood clot.", + "A transvaginal ultrasound scan showed a large endometrial mass with calcification.", + "She underwent a hysteroscopy in July 2007 when a 6 cm uterine fibrotic polyp, which filled the uterine cavity, was removed.", + "Microscopy demonstrated polypoid tissue with a variably cellular and fibrotic stroma.", + "The glands showed focal mucinous and keratinising squamous epithelial metaplasia.", + "There was focal nuclear atypia, focal mitotic activity and occasional cribriform gland fusion.", + "These features were in keeping with either atypical complex hyperplasia within an endometrial polyp associated with metaplastic changes, or a polypoid uterine teratoma.", + "Immunohistochemistry showed positive staining of the small crowded epithelium for the epithelial marker cytokeratin (CK)-7 and the thyroid and lung marker TTFI.", + "There was positive staining of the chondroid area for S100 protein.", + "Thyroglobulin, desmin, CK20 and CDX2 staining was negative.", + "A diagnosis of benign teratoma with thyroid gland and cartilaginous elements was therefore made.", + "Following hysteroscopy, the bleeding continued.", + "A repeat ultrasound scan revealed that the teratoma had grown back almost completely filling the uterine cavity.", + "An MRI scan in November 2007 showed the tumour filling and distending the endometrial cavity and extending down into the cervix.", + "There was evidence of posterior wall myometrial invasion but there was no lymphadenopathy and the ovaries appeared normal.", + "Tumour markers including alpha-fetoprotein (AFP), carcinoembryonic antigen (CEA) and Ca19-9 were within normal limits.", + "Serum Ca125 was slightly elevated at 42 U/ml.", + "Lactate dehydrogenase (LDH) was raised at 372 IU/L.", + "The patient proceeded to a total abdominal hysterectomy and bilateral salpingo-oophorectomy in December 2007.", + "At operation, the uterus was found to contain a haemorrhagic polypoid tumour (110 × 80 × 70 mm) arising from the posterior aspect of the endometrial cavity.", + "Microscopically the tumour was a teratoma containing mature and immature elements with mixed malignant transformation.", + "The tissue types found included squamous and glandular epithelium, thyroid parenchyma, smooth muscle, connective and adipose tissue.", + "There were areas of immature bone, invasive adenocarcinoma, and papillary thyroid carcinoma.", + "There was extensive lymphovascular invasion and deep myometrial, but not serosal, involvement.", + "The omentum, cervix, fallopian tubes and ovaries were free of tumour.", + "Immunohistochemistry showed that the malignant epithelial components were positive for CK-7 and TTF-1, but negative for CK20 and thyroglobulin.", + "One area of the tumour stained positive for desmin but not for SMA, S100 or CD10, suggesting that this is likely to be a small focus of myogenic sarcoma.", + "The histopathological conclusion was of a poorly differentiated adenocarcinoma and a focal myogenic sarcoma arising in a polypoid uterine teratoma with mature and immature elements.", + "A post-operative CT scan of the thorax, abdomen and pelvis found no evidence of distant disease giving an overall International Federation of Gynaecology and Obstetrics disease stage 1C.", + "The patient recovered well from surgery and was referred for oncological follow up.", + "Given her age and performance status a surveillance approach was taken with regular clinical examinations, serial tumour markers and routine CT scans.", + "Initially in remission, six months post-operatively para-aortic lymphadenopathy was detected on CT although she remained asymptomatic with an ECOG performance status of 0.", + "In view of her age and wishes for a treatment with acceptable toxicity, the patient was commenced on an initial dose of cisplatin (20 mg/m2) and etoposide (100 mg/m2).", + "This was well tolerated so one week later treatment was continued with a fortnightly alternating regimen of paclitaxel (135 mg/m2) and etoposide (150 mg/m2), followed by paclitaxel (135 mg/m2) and cisplatin (60 mg/m2).", + "After three cycles of chemotherapy there was a reduction in the size of the para-aortic mass, but an increase in the cystic component suggesting possible differentiation towards a mature teratoma.", + "She underwent a retro-peritoneal lymph node dissection in October 2008.", + "Histology from this confirmed the presence of metastatic teratoma.", + "She had a turbulent post-operative course and, although she recovered well enough to return home a month later, she sadly died shortly thereafter." + ], + "summary": "We report an 82-year-old lady presenting with post-menopausal bleeding. Initial investigations revealed a benign teratoma of the uterus which was removed. Her symptoms persisted and a recurrent, now malignant, teratoma of the uterine corpus was resected at hysterectomy. Six months after surgery she relapsed with para-aortic lymphadenopathy and was treated with a taxane, etoposide and cisplatin-containing chemotherapy regimen followed by retroperitoneal lymph node dissection.", + "summary_subclaims": [ + "The patient is an 82-year-old lady.", + "She presented with post-menopausal bleeding.", + "Initial investigations revealed a benign teratoma of the uterus.", + "The benign teratoma was removed.", + "Her symptoms persisted after removal of the benign teratoma.", + "A recurrent teratoma of the uterine corpus was resected at hysterectomy.", + "The recurrent teratoma was malignant.", + "Six months after surgery she relapsed with para-aortic lymphadenopathy.", + "She was treated with a taxane, etoposide and cisplatin-containing chemotherapy regimen.", + "She underwent retroperitoneal lymph node dissection." + ] + }, + { + "id": "multiclinsum_test_507_en.txt", + "fulltext": "A 49-year-old Caucasian male was referred to Cardiology Clinic with progressive shortness of breath on exertion; New York Heart Association (NYHA) functional Class II. He denied any other symptoms suggestive of heart failure, arrhythmias, or ischaemia. He had no history of diabetes mellitus, hypertension, respiratory illnesses, renal disease, or coronary artery disease. The patient smoked since adolescence but quit 4 years prior to his visit. The patient was not on chronic medications. He was estranged from his family for a very long time, and he had no details about their medical history or care.\nOn physical examination, the patient was found to be tall at 198 cm, and weighed 101 kg. He had a blood pressure of 90/60 mmHg sitting, heart rate of 70 beats per minute, cardiovascular examination revealed jugular venous pulsation to be within normal limits, a normal S1 and S2, no S3 or S4, and a systolic ejection murmur, Grade 1/6 on the Levine scale, over the aortic area with no radiation. There was no evidence of heart failure, including no pedal oedema. He had a positive wrist sign, and dysmorphic features including enophthalmos, malar hypoplasia, retrognathia, and pectus carinatum. The rest of his physical examination was unremarkable.\nLaboratory workup included a normal haemoglobin and creatine of 151 g/L and 84 μmol/L, respectively. Electrolytes and liver function results were within normal limits.\nAn electrocardiogram was performed and was normal . Heart failure biomarkers (BNP or NT-proBNP) would have been useful to diagnose heart failure but were not available within the regional health care system. He underwent stress myocardial perfusion imaging that ruled out ischaemia but demonstrated a left ventricular ejection fraction (LVEF) of 36% at rest and 43% post-stress. A transthoracic echocardiogram revealed left ventricular (LV) global hypokinesis, with LVEF of 40–45%. There was mild aortic insufficiency. The aortic root was dilated at 4.9 cm in diameter and Z-score of 4.66 .\nComputed tomography angiography of the thoracic aorta revealed dilated coronary sinuses at 4.4 cm × 4.6 cm × 4.8 cm . A cardiac MRI study revealed a mildly reduced LVEF at 43%, with evidence of mild concentric LV hypertrophy (Video 1).\nGiven the patient’s clinical features, and the dilated aortic root, MFS was suspected, but he did not meet the criteria for diagnosis when applying the revised Ghent Criteria for Diagnosing Marfan Syndrome , with only the presence of aortic Z-score > 2 and 4 points for systemic findings. Therefore, genetic investigations were sent. The molecular genetics report for MFS and related aortopathies revealed that this patient is heterozygous for a sequence variant in the fibrillin-1 gene (FBN1), designated NM_000138.4: c.7016G>C , which is predicted to result in the amino acid substitution p. Cys2339Ser. Cysteine residues in fibrillin-1 (FBN1) form disulfide bonds which are important for proper protein folding. The substitution of a different amino acid in FBN1 can create or destroy a cysteine residue and results in disruption of the disulfide bonds which causes protein misfolding that has been reported to cause MFS phenotypes., This particular variant has not been reported previously and is absent in the Genome Aggregation Database (GnomAD) population database, as well as ClinVar, which are the resources that aggregate, harmonize, and archive sequencing data and the relationships among genetic variations and phenotypes.\nDifferent substitutions affecting the same amino acid residue (p.Cys2339Tyr; p. Cys2339Arg; p. Cys2339Gly) were reported to be pathogenic for MFS.,\nThe patient was started on ramipril and metoprolol with titration as tolerated. According to guideline recommendations,, the patient underwent a valve-sparing root replacement, an excellent outcome, and recovery . There were no postoperative complications. At 13 months of follow-up, the patient’s shortness of breath was resolved and he was pleased to return to his excellent premorbid status. The patient’s echocardiogram at 13 months post-operatively revealed an intact aortic repair and graft, with only mild aortic valve insufficiency and an improved LVEF at 55%. The patient remains clinically well.", + "fulltext_subclaims": [ + "The patient is a 49-year-old Caucasian male.", + "He was referred to Cardiology Clinic with progressive shortness of breath on exertion.", + "He was classified as New York Heart Association (NYHA) functional Class II.", + "He denied any other symptoms suggestive of heart failure, arrhythmias, or ischaemia.", + "He had no history of diabetes mellitus.", + "He had no history of hypertension.", + "He had no history of respiratory illnesses.", + "He had no history of renal disease.", + "He had no history of coronary artery disease.", + "He smoked since adolescence but quit 4 years prior to his visit.", + "He was not on chronic medications.", + "He was estranged from his family for a very long time.", + "He had no details about their medical history or care.", + "On physical examination, the patient was found to be 198 cm tall.", + "He weighed 101 kg.", + "He had a blood pressure of 90/60 mmHg sitting.", + "He had a heart rate of 70 beats per minute.", + "Cardiovascular examination revealed jugular venous pulsation within normal limits.", + "Cardiovascular examination revealed a normal S1 and S2.", + "There was no S3 or S4 heard.", + "There was a systolic ejection murmur, Grade 1/6 on the Levine scale, over the aortic area with no radiation.", + "There was no evidence of heart failure.", + "There was no pedal oedema.", + "He had a positive wrist sign.", + "He had dysmorphic features including enophthalmos, malar hypoplasia, retrognathia, and pectus carinatum.", + "The rest of his physical examination was unremarkable.", + "Laboratory workup included a normal haemoglobin of 151 g/L.", + "Laboratory workup included a normal creatine of 84 μmol/L.", + "Electrolytes and liver function results were within normal limits.", + "An electrocardiogram was performed and was normal.", + "Heart failure biomarkers (BNP or NT-proBNP) would have been useful to diagnose heart failure but were not available within the regional health care system.", + "Stress myocardial perfusion imaging ruled out ischaemia.", + "Stress myocardial perfusion imaging demonstrated a left ventricular ejection fraction (LVEF) of 36% at rest and 43% post-stress.", + "A transthoracic echocardiogram revealed left ventricular (LV) global hypokinesis.", + "The transthoracic echocardiogram showed an LVEF of 40–45%.", + "There was mild aortic insufficiency.", + "The aortic root was dilated at 4.9 cm in diameter.", + "The aortic root had a Z-score of 4.66.", + "Computed tomography angiography of the thoracic aorta revealed dilated coronary sinuses at 4.4 cm × 4.6 cm × 4.8 cm.", + "A cardiac MRI study revealed a mildly reduced LVEF at 43%.", + "The cardiac MRI study showed evidence of mild concentric LV hypertrophy.", + "Marfan Syndrome (MFS) was suspected.", + "The patient did not meet the criteria for diagnosis when applying the revised Ghent Criteria for Diagnosing Marfan Syndrome.", + "The patient had aortic Z-score > 2.", + "The patient had 4 points for systemic findings.", + "Genetic investigations were sent.", + "The molecular genetics report revealed the patient is heterozygous for a sequence variant in the fibrillin-1 gene (FBN1), designated NM_000138.4: c.7016G>C.", + "The variant is predicted to result in the amino acid substitution p. Cys2339Ser.", + "Cysteine residues in fibrillin-1 (FBN1) form disulfide bonds important for proper protein folding.", + "The substitution of a different amino acid in FBN1 can create or destroy a cysteine residue.", + "The substitution results in disruption of the disulfide bonds which causes protein misfolding.", + "Protein misfolding has been reported to cause MFS phenotypes.", + "This particular variant has not been reported previously.", + "This variant is absent in the Genome Aggregation Database (GnomAD) population database.", + "This variant is absent in ClinVar.", + "Different substitutions affecting the same amino acid residue (p.Cys2339Tyr; p. Cys2339Arg; p. Cys2339Gly) were reported to be pathogenic for MFS.", + "The patient was started on ramipril.", + "The patient was started on metoprolol.", + "The patient underwent a valve-sparing root replacement.", + "The patient had an excellent outcome.", + "There were no postoperative complications.", + "At 13 months of follow-up, the patient’s shortness of breath was resolved.", + "The patient was pleased to return to his excellent premorbid status.", + "The patient’s echocardiogram at 13 months post-operatively revealed an intact aortic repair and graft.", + "The patient’s echocardiogram at 13 months post-operatively showed only mild aortic valve insufficiency.", + "The patient’s echocardiogram at 13 months post-operatively showed an improved LVEF at 55%.", + "The patient remains clinically well." + ], + "summary": "We identified a 49-year-old patient who presented with dyspnoea, with Marfan syndrome (MFS) and a previously unreported variant in the fibrillin-1 gene (FBN1), designated c.7016G>C. Prior to identifying the new gene variant, this patient did not meet the revised Ghent criteria for MFS diagnosis. We present clinical and molecular evidence supporting the likely pathogenic nature of this variant, leading to earlier therapy and intervention.", + "summary_subclaims": [ + "The patient was 49 years old.", + "The patient presented with dyspnoea.", + "The patient had Marfan syndrome.", + "The patient had a previously unreported variant in the FBN1 gene.", + "The variant was designated c.7016G>C.", + "Prior to identifying the new gene variant, the patient did not meet the revised Ghent criteria for MFS diagnosis.", + "Clinical and molecular evidence supports the likely pathogenic nature of this variant.", + "The variant led to earlier therapy and intervention." + ] + }, + { + "id": "multiclinsum_test_2262_en.txt", + "fulltext": "A 49-year-old male was admitted to Nephrology Department for oedema for 1 month and dyspnea for 1 week, with painful livedo reticularis in his left foot. His past history included recurrent episodes of brucellosis over the past four years. Two months prior to admission, brucellosis reoccurred and doxycycline and rifampin had been taken for 6 weeks and his symptoms of fever, sweating and general malaise disappeared. He had hypertension for 10 years, treated with telmisartan, nifedipine and indapamide and his blood pressure was about 150/90 mmHg. He underwent an iliac aneurysm stent implantation 6 years ago. He self-reported no evidence of renal disease before.\nOn admission, the patient had no fever, and his blood pressure was 163/111 mmHg. Clinical examination revealed a puffy and pale appearance, general oedema, weakened breath sound in the bottom of both lungs and moist rales heard in both lungs. The ischemic manifestation occurred in the left lower limb including cold skin temperature and pulseless in arteria dorsalis pedis. Livedoid changes in the left sole were in Fig. .\nLaboratory tests showed elevated blood white blood cell (WBC) count with increased neutrophil ratio (WBC: 13.2 × 109/L and 90% neutrophil). The hemoglobin was 8.1 mg/dL. Urinalysis showed 2 + protein with dysmorphic red blood cells (77–430 /HP). Total urine protein excretion was 2.1 g/day. Blood urea nitrogen was 20.3 mmol/L, serum creatinine 203 µmol/L and creatinine clearance 31.9 mL/min/1.73 m2. Serum albumin was 23.4 g/L. Serum brain natriuretic peptide was 4087.3 µg/mL. Parathyroid hormone was 219.3 pg/mL. C-reaction protein was 53.2 g/L. Hypocomplementemia with C3 0.197 g/L and C4 0.101 g/L. Rheumatoid factor, anti-nuclear antibody IgG, cytoplasmic ANCA and proteinase 3 ANCA were positive. Reversible cryoprecipitate appeared and serum cryoglobulin level was 1.53 g/L. Immunoelectrophoretic analysis of the serum cryoglobulin showed the mixed polyclonal IgG and IgM . Brucella serum agglutinins test (SAT) was positive at a titer of 1:200 and both the blood and the bone marrow culture were negative.\nThe pulmonary computed tomography (CT) scan showed a bilateral exudative lesion, bilateral pleural effusion and pulmonary atelectasis with pericardial effusion. The abdominal CT showed peritoneal and pelvic effusion, diffused abdominal wall oedema, metal stents image in the abdominal aorta, bilateral common iliac arteries and left external iliac artery. The electrocardiogram showed sinus rhythm with left ventricular high voltage. Ultrasonographic imaging of the kidneys revealed normal-sized kidneys with increased parenchymal echogenicity. The transthoracic echocardiogram detected enlargement in all four chambers and myocardial wall hypokinesia with decreased ejection fracture of 41%. Other changes included moderate pulmonary artery hypertension and a small amount of pericardial effusion with no vegetation on the cardiac valves. Pathological examination of the bone marrow showed hyperplasia of bone marrow with a normal ratio of granulocytes to erythrocytes. No poisoning particle was present in granulocytes. no parasites or bacteria were found.\nThe patient received continuous renal replacement therapy (CRRT) to relieve the dyspnea and heavy oedema. A renal biopsy was performed after the patient’s condition become stable. The renal pathology revealed endocapillary proliferative glomerulonephritis with crescent formation. Hypertensive renal injury was also prominent . On light microscopy, 32 glomeruli were identified. Glomerular sclerosis in 11 glomeruli. Hypercellularity in the remaining glomeruli, mainly endothelial cells and mesangial cells with a few neutrophils. A cellular, a fibrinous and a small cellulofibrous crescent were found. No basement membrane thickening. Severe vacuole and granular denaturation in tubular epithelial cells. 40% tubular atrophy, mild tubular interstitial oedema and multiple inflammatory cells infiltration with fibrosis. Thickening and narrowing of arteriole wall with segmental hyalinization. The immunofluorescence revealed diffuse strong C3 deposits along the capillary wall. No other immunoglobulin or complement deposit was present. Hump-like electron-dense deposits were found under epithelial cells by electron microscopy superimposed on hypertensive renal injury contributed to the patient’s renal involvement.\nThe patient was diagnosed with acute post-infectious glomerulonephritis (APIGN), AAV- related glomerulonephritis, secondary cryoglobulinemia, acute kidney injury on chronic kidney disease, primary hypertension Grade 3 (very high risk), congestive heart failure. Methylprednisolone (40 mg/QD/IV) was given on the 3rd day of admission to treat the acute nephritic syndrome. More important was the presence of ANCA and other immunological disorders and the severe foot pain and livedo reticularis which was a skin vasculitis related to cryoglobulinemia. And all the symptoms of the patient were relieved promptly and no need for CRRT treatment. Oral prednisone 50 mg per day was used and the patient was discharged from the hospital. For the treatment of brucellosis, anti-brucellosis treatment was suggested at the same time though the patient had no sign of active infection. Doxycycline and rifampin were added with a prolonged course of 6 months.\nThe patient recovered soon and on the 1st follow-up one month later, oral cortisone began to taper. 2 months later the prednisone was tapered to 30 mg/day and on the 3rd month, prednisone was 10 mg per day. The patient felt well and had no oedema, no fever and no dyspnea. The foot pain and livedo reticularis disappeared. There were little proteinuria and a slightly elevated creatinine level left. Now the patient is still under intensive follow-up. The biochemical examination records were listed in Table .\nAntihypertensive treatment was given at the very beginning. Sacubitril/valsartan was given to reduce the elevated blood pressure and reverse the enlarged ventricle accompanied by amlodipine and arotinolol. Now the sacubitril/valsartan was used at the maximal dose (200 mg bid) and blood pressure is well controlled under 130/80 mmHg. The Echocardiography re-checked 3 weeks later showed left ventricular enlargement only and improved ventricular motion with an improved ejection fraction of 53%. There was still 5–8 mm pericardial effusion and no pulmonary hypertension.\nThe patient worked as a shepherd from 2012 to 2015. But he was first diagnosed with brucellosis 2 years after ceasing sheep husbandry with classical symptoms of fever, sweating, muscle pain and ankle pain. After combined use of oral doxycycline and rifampin for 6 weeks. His symptoms disappeared completely. But his symptoms were repeated another 3 times. Each time he was treated with the same therapeutic regimen and responded well. But his brucella antibody persists positive which may be a sign of inadequate treatment.", + "fulltext_subclaims": [ + "The patient is a 49-year-old male.", + "He was admitted to the Nephrology Department.", + "He had oedema for 1 month.", + "He had dyspnea for 1 week.", + "He had painful livedo reticularis in his left foot.", + "His past history included recurrent episodes of brucellosis over the past four years.", + "Two months prior to admission, brucellosis reoccurred.", + "He had taken doxycycline and rifampin for 6 weeks.", + "His symptoms of fever, sweating, and general malaise disappeared.", + "He had hypertension for 10 years.", + "He was treated with telmisartan, nifedipine, and indapamide.", + "His blood pressure was about 150/90 mmHg.", + "He underwent an iliac aneurysm stent implantation 6 years ago.", + "He self-reported no evidence of renal disease before.", + "On admission, the patient had no fever.", + "His blood pressure was 163/111 mmHg.", + "Clinical examination revealed general oedema.", + "Weakened breath sound in the bottom of both lungs was noted.", + "Moist rales were heard in both lungs.", + "The ischemic manifestation occurred in the left lower limb.", + "Livedoid changes in the left sole were in Fig.", + "Laboratory tests showed elevated blood white blood cell count.", + "The WBC count was 13.2 × 109/L.", + "The neutrophil ratio was 90%.", + "The hemoglobin was 8.1 mg/dL.", + "Urinalysis showed 2 + protein.", + "Dysmorphic red blood cells were 77–430 /HP.", + "Total urine protein excretion was 2.1 g/day.", + "Blood urea nitrogen was 20.3 mmol/L.", + "Serum creatinine was 203 µmol/L.", + "Creatinine clearance was 31.9 mL/min/1.73 m2.", + "Serum albumin was 23.4 g/L.", + "Serum brain natriuretic peptide was 4087.3 µg/mL.", + "Parathyroid hormone was 219.3 pg/mL.", + "C-reaction protein was 53.2 g/L.", + "Hypocomplementemia with C3 0.197 g/L.", + "C4 was 0.101 g/L.", + "Rheumatoid factor was positive.", + "Anti-nuclear antibody IgG was positive.", + "Cytoplasmic ANCA was positive.", + "Proteinase 3 ANCA was positive.", + "Reversible cryoprecipitate appeared.", + "Serum cryoglobulin level was 1.53 g/L.", + "Immunoelectrophoretic analysis showed mixed polyclonal IgG and IgM.", + "Brucella serum agglutinins test was positive at a titer of 1:200.", + "Blood culture was negative.", + "Bone marrow culture was negative.", + "The pulmonary CT scan showed bilateral exudative lesions.", + "Bilateral pleural effusion was present.", + "Pulmonary atelectasis was present.", + "Pericardial effusion was present.", + "The abdominal CT showed peritoneal and pelvic effusion.", + "Diffused abdominal wall oedema was present.", + "Metal stents were seen in the abdominal aorta.", + "The electrocardiogram showed sinus rhythm.", + "Left ventricular high voltage was noted.", + "Ultrasonographic imaging showed normal-sized kidneys.", + "Increased parenchymal echogenicity was noted.", + "The transthoracic echocardiogram detected enlargement in all four chambers.", + "Myocardial wall hypokinesia was present.", + "Ejection fraction was 41%.", + "Moderate pulmonary artery hypertension was present.", + "A small amount of pericardial effusion was present.", + "No vegetation was present on the cardiac valves.", + "Pathological examination of the bone marrow showed hyperplasia.", + "The granulocyte to erythrocyte ratio was normal.", + "No poisoning particle was present in granulocytes.", + "No parasites or bacteria were found.", + "The patient received continuous renal replacement therapy.", + "A renal biopsy was performed after the patient’s condition became stable.", + "The renal pathology revealed endocapillary proliferative glomerulonephritis.", + "Crescent formation was present.", + "Hypertensive renal injury was prominent.", + "On light microscopy, 32 glomeruli were identified.", + "Glomerular sclerosis was present in 11 glomeruli.", + "Hypercellularity was present in the remaining glomeruli.", + "A cellular, a fibrinous, and a small cellulofibrous crescent were found.", + "No basement membrane thickening was present.", + "Severe vacuole and granular denaturation in tubular epithelial cells was noted.", + "40% tubular atrophy was present.", + "Mild tubular interstitial oedema was present.", + "Multiple inflammatory cells infiltration with fibrosis was present.", + "Thickening and narrowing of arteriole wall with segmental hyalinization was present.", + "The immunofluorescence revealed diffuse strong C3 deposits along the capillary wall.", + "No other immunoglobulin or complement deposit was present.", + "Hump-like electron-dense deposits were found under epithelial cells by electron microscopy.", + "The deposits were superimposed on hypertensive renal injury.", + "The patient was diagnosed with acute post-infectious glomerulonephritis.", + "AAV-related glomerulonephritis was present.", + "Secondary cryoglobulinemia was present.", + "Acute kidney injury on chronic kidney disease was present.", + "Primary hypertension Grade 3 (very high risk) was present.", + "Congestive heart failure was present.", + "Methylprednisolone 40 mg/QD/IV was given on the 3rd day of admission.", + "The presence of ANCA and other immunological disorders was noted.", + "Severe foot pain and livedo reticularis were present.", + "The symptoms were a skin vasculitis related to cryoglobulinemia.", + "All the symptoms of the patient were relieved promptly.", + "No need for CRRT treatment was present.", + "Oral prednisone 50 mg per day was used.", + "The patient was discharged from the hospital.", + "Anti-brucellosis treatment was suggested.", + "Doxycycline and rifampin were added.", + "The course was prolonged to 6 months.", + "The patient recovered soon.", + "On the 1st follow-up one month later, oral cortisone began to taper.", + "Two months later, prednisone was tapered to 30 mg/day.", + "On the 3rd month, prednisone was 10 mg per day.", + "The patient felt well.", + "He had no oedema.", + "He had no fever.", + "He had no dyspnea.", + "The foot pain and livedo reticularis disappeared.", + "There were little proteinuria.", + "A slightly elevated creatinine level was present.", + "The patient is still under intensive follow-up.", + "Antihypertensive treatment was given at the very beginning.", + "Sacubitril/valsartan was given.", + "Amlodipine and arotinolol were given.", + "Sacubitril/valsartan was used at the maximal dose (200 mg bid).", + "Blood pressure was well controlled under 130/80 mmHg.", + "The echocardiography re-checked 3 weeks later showed left ventricular enlargement only.", + "Improved ventricular motion was noted.", + "Ejection fraction improved to 53%.", + "There was still 5–8 mm pericardial effusion.", + "No pulmonary hypertension was present.", + "The patient worked as a shepherd from 2012 to 2015.", + "He was first diagnosed with brucellosis 2 years after ceasing sheep husbandry.", + "He had classical symptoms of fever, sweating, muscle pain, and ankle pain.", + "After combined use of oral doxycycline and rifampin for 6 weeks, his symptoms disappeared completely.", + "His symptoms were repeated another 3 times.", + "Each time he was treated with the same therapeutic regimen.", + "He responded well.", + "His brucella antibody persists positive.", + "This may be a sign of inadequate treatment." + ], + "summary": "A 49-year-old man with hypertension and iliac aortic stent implantation was admitted for unexplained renal failure with signs of nephritic syndrome, congestive heart failure, moderate anemia and livedoid change in the left sole with pain. His past history included chronic brucellosis and he just underwent the recurrence and completed the 6 weeks of antibiotics treatment. He demonstrated positive cytoplasmic/proteinase 3 ANCA, mixed type cryoglobulinemia and decreased C3. The kidney biopsy revealed endocapillary proliferative glomerulonephritis with a small amount of crescent formation. Immunofluorescence staining revealed only C3-positive staining. In accordance with clinical and laboratory findings, post-infective acute glomerulonephritis superimposed with AAV was diagnosed. The patient was treated with corticosteroids and antibiotics and sustained alleviation of renal function and brucellosis was achieved during the course of a 3-month follow-up.", + "summary_subclaims": [ + "The patient is a 49-year-old man.", + "The patient has hypertension.", + "The patient had iliac aortic stent implantation.", + "The patient was admitted for unexplained renal failure.", + "The patient had signs of nephritic syndrome.", + "The patient had congestive heart failure.", + "The patient had moderate anemia.", + "The patient had livedoid change in the left sole with pain.", + "The patient had a history of chronic brucellosis.", + "The patient just underwent recurrence and completed 6 weeks of antibiotics treatment.", + "The patient had positive cytoplasmic/proteinase 3 ANCA.", + "The patient had mixed type cryoglobulinemia.", + "The patient had decreased C3.", + "The kidney biopsy revealed endocapillary proliferative glomerulonephritis.", + "The kidney biopsy showed a small amount of crescent formation.", + "Immunofluorescence staining revealed only C3-positive staining.", + "Post-infective acute glomerulonephritis superimposed with AAV was diagnosed.", + "The patient was treated with corticosteroids.", + "The patient was treated with antibiotics.", + "The patient sustained alleviation of renal function.", + "The patient sustained alleviation of brucellosis.", + "The patient had a 3-month follow-up." + ] + }, + { + "id": "multiclinsum_test_2381_en.txt", + "fulltext": "In 2003, the Department of Oral Pathology and Surgery at the School of Dentistry, University of Athens referred a young 22-year-old female with Hajdu-Cheney Syndrome (HCS) to the Postgraduate Clinic of the Department of Periodontology, in order to receive periodontal treatment . The patient was diagnosed in 2001 with HCS after clinical, radiographic and histological examination . After gene examination of both parents, none of them was found bearing a mutation in the NOTCH2 gene . Her physical examination showed that her height was 145cm and her weight was 45kg. The patient had thick coarse hair, low-set ears, small face and stature, thin lips, small mouth and short hands with clubbing of the fingertips . According to her medical history, the patient suffered from emphysema and allergic rhinitis, whereas oral intake of Vitamin D and calcium were prescribed daily for the treatment of osteoporosis [, ].\nDuring orthodontic treatment between the ages of 12 and 21 years, all of her first premolars were removed . At the age of 20 years, the patient received non-surgical periodontal treatment (scaling and root surface debridement), as well as limited periodontal surgery in the lower anterior region [, ]. Detailed records regarding both orthodontic and periodontal treatment were not available. The patient was a non-smoker, visited her dentist every 6 months, brushed her teeth twice every day (Bass technique) and used dental floss and interdental brushes. At the time of the referral, the patient suffered from generalized advanced chronic periodontitis, increased tooth mobility and premature tooth loss . Clinical and radiographic examination of both parents and her 4 years younger brother showed that the mother and the younger brother had normal dentition, whereas the father was diagnosed with chronic advanced periodontal disease with increased mobility of various teeth.\nThe patient was treated in collaboration with the Department of Prosthodontics. Clinical and radiographic examination of the patient revealed a number of significant findings. There was generalized horizontal bone loss of ~ 50%. However, alveolar bone loss around various teeth such as #4 (in place of #5), 14 and 24 was extensive (~ 100%). Tooth roots appeared short and cervical, whereas cervical resorption lesions were also evident (teeth #3, 10, 20 (in place of #19), 26) [, ]. The patient received non-surgical periodontal treatment in all four quadrants, which included scaling and root surface debridement. During this period, teeth #4, 14 and 24 were extracted due to extensive alveolar bone loss . The maxilla was then rehabilitated with the placement of a provisional fixed partial denture of metal acrylic and the anterior region of the mandible with the placement of a Maryland bridge . Upon completion of the periodontal treatment, the patient was enrolled in a periodontal maintenance program.\nAfter careful consideration of the possible implications deriving from the patient’s condition (osteoporosis, generalized advanced periodontitis) and having taken her young age into account, we decided to proceed with the placement of dental implants, while implementing specific protocols such as longer healing periods. So, although in the current literature no other case of implant placement in a patient with HCS was described, in February 2005, a dental implant (Nobel Biocare, Replace Select Straight, TiUnite RP 4.3 x 13mm) was placed in the upper right first premolar region .\nDuring the healing period, in March 2009, further teeth were extracted (#2,3,30). During the extraction of tooth #30, a bovine xenograft (Geistlich Bio-Oss Collagen 250 mg) was placed in the post-extraction site, in order to achieve ridge preservation and the region was rehabilitated with a resin-bonded bridge (Maryland bridge).\nFive years after placement and successful osseointegration of the dental implant in position #5, an additional implant (Nobel Biocare, Replace Select Tapered TiUnite Regular Platform (RP) 4.3 x 8mm) was placed in the upper right first molar region . Bone mineral density appeared physiological (Bone Type III) .\nSix months after implant placement, a porcelain fused to metal, three unit implant supported fixed partial denture 3 (4) 5 was placed in the upper right region . During this period of time, teeth # 18, 19 were extracted due to excessive bone loss.\nClinical and radiographic examination of the patient during the periodontal maintenance program in three months interval after implant placement revealed no abnormalities in the implant region. After successful oral rehabilitation of the posterior upper right region, 2 additional dental implants were placed in the posterior left region (during surgery tooth #20 - in place of #21- was extracted) and 1 in the posterior right region of the mandible (Straumann Standard Platform (SP) Tissue Level) .\nSix months after implant placement, a porcelain fused to metal, three unit implant supported fixed partial denture 19 18 was placed in the left region of the mandible, whereas a porcelain fused to metal implant supported crown was placed in the right region of the mandible .\nFive years after implant placement, clinical and radiographic examination of the patient during the periodontal maintenance program (in three months interval) revealed no abnormalities .\nFor the reader’s better understanding, Table presents the patient’s detailed dental treatment chronologically.", + "fulltext_subclaims": [ + "The Department of Oral Pathology and Surgery at the School of Dentistry, University of Athens referred a 22-year-old female with Hajdu-Cheney Syndrome to the Postgraduate Clinic of the Department of Periodontology.", + "The patient was diagnosed with Hajdu-Cheney Syndrome in 2001 after clinical, radiographic, and histological examination.", + "After gene examination of both parents, none of them was found bearing a mutation in the NOTCH2 gene.", + "The patient's height was 145cm and her weight was 45kg.", + "The patient had thick coarse hair, low-set ears, small face and stature, thin lips, small mouth, and short hands with clubbing of the fingertips.", + "The patient suffered from emphysema and allergic rhinitis.", + "Oral intake of Vitamin D and calcium were prescribed daily for the treatment of osteoporosis.", + "During orthodontic treatment between the ages of 12 and 21 years, all of her first premolars were removed.", + "At the age of 20 years, the patient received non-surgical periodontal treatment (scaling and root surface debridement), as well as limited periodontal surgery in the lower anterior region.", + "Detailed records regarding both orthodontic and periodontal treatment were not available.", + "The patient was a non-smoker, visited her dentist every 6 months, brushed her teeth twice every day (Bass technique), and used dental floss and interdental brushes.", + "At the time of the referral, the patient suffered from generalized advanced chronic periodontitis, increased tooth mobility, and premature tooth loss.", + "Clinical and radiographic examination of the patient's father showed that he was diagnosed with chronic advanced periodontal disease with increased mobility of various teeth.", + "Clinical and radiographic examination of the patient revealed generalized horizontal bone loss of ~ 50%.", + "Alveolar bone loss around various teeth such as #4, 14, and 24 was extensive (~ 100%).", + "Tooth roots appeared short and cervical.", + "Cervical resorption lesions were evident in teeth #3, 10, 20, and 26.", + "The patient received non-surgical periodontal treatment in all four quadrants, which included scaling and root surface debridement.", + "Teeth #4, 14, and 24 were extracted due to extensive alveolar bone loss.", + "The maxilla was rehabilitated with the placement of a provisional fixed partial denture of metal acrylic.", + "The anterior region of the mandible was rehabilitated with the placement of a Maryland bridge.", + "The patient was enrolled in a periodontal maintenance program.", + "In February 2005, a dental implant (Nobel Biocare, Replace Select Straight, TiUnite RP 4.3 x 13mm) was placed in the upper right first premolar region.", + "In March 2009, further teeth were extracted (#2, 3, 30).", + "During the extraction of tooth #30, a bovine xenograft (Geistlich Bio-Oss Collagen 250 mg) was placed in the post-extraction site.", + "Five years after placement and successful osseointegration of the dental implant in position #5, an additional implant (Nobel Biocare, Replace Select Tapered TiUnite Regular Platform (RP) 4.3 x 8mm) was placed in the upper right first molar region.", + "Bone mineral density appeared physiological (Bone Type III).", + "Six months after implant placement, a porcelain fused to metal, three unit implant supported fixed partial denture 3 (4) 5 was placed in the upper right region.", + "During this period, teeth #18 and 19 were extracted due to excessive bone loss.", + "Clinical and radiographic examination of the patient during the periodontal maintenance program in three months interval after implant placement revealed no abnormalities in the implant region.", + "After successful oral rehabilitation of the posterior upper right region, 2 additional dental implants were placed in the posterior left region (during surgery tooth #20 - in place of #21 - was extracted) and 1 in the posterior right region of the mandible (Straumann Standard Platform (SP) Tissue Level).", + "Six months after implant placement, a porcelain fused to metal, three unit implant supported fixed partial denture 19 18 was placed in the left region of the mandible.", + "A porcelain fused to metal implant supported crown was placed in the right region of the mandible.", + "Five years after implant placement, clinical and radiographic examination of the patient during the periodontal maintenance program (in three months interval) revealed no abnormalities." + ], + "summary": "A 22-year old woman with osteoporosis, generalized advanced chronic periodontitis and premature tooth loss was referred to the Postgraduate Clinic of Periodontology, University of Athens-Greece. The patient was diagnosed in 2001 with HCS. The patient received non-surgical periodontal treatment and several teeth were extracted due to extensive alveolar bone loss. After careful consideration of the possible implications deriving from the patient's condition and having taken her young age into account, initially, a dental implant was placed in the upper right first premolar region. Specific protocols such as longer healing periods were implemented, so five years after placement and successful osseointegration of this implant, four additional dental implants were placed in the posterior regions of the maxilla and the mandible. Prosthetic rehabilitation followed 6 months after implant placement. Upon completion of periodontal treatment, the patient was enrolled in a periodontal maintenance program.", + "summary_subclaims": [ + "A 22-year old woman with osteoporosis, generalized advanced chronic periodontitis and premature tooth loss was referred to the Postgraduate Clinic of Periodontology, University of Athens-Greece.", + "The patient was diagnosed in 2001 with HCS.", + "The patient received non-surgical periodontal treatment.", + "Several teeth were extracted due to extensive alveolar bone loss.", + "After careful consideration of the possible implications deriving from the patient's condition and having taken her young age into account, initially, a dental implant was placed in the upper right first premolar region.", + "Specific protocols such as longer healing periods were implemented.", + "Five years after placement and successful osseointegration of this implant, four additional dental implants were placed in the posterior regions of the maxilla and the mandible.", + "Prosthetic rehabilitation followed 6 months after implant placement.", + "Upon completion of periodontal treatment, the patient was enrolled in a periodontal maintenance program." + ] + }, + { + "id": "multiclinsum_test_1794_en.txt", + "fulltext": "An 80-year-old Caucasian woman was admitted to our hospital with a 12-year history of an endocrine inactive steady sellar mass lesion (13 mm in diameter; Figure ). Our patient had been previously asymptomatic with no pituitary hormone deficiency or visual impairments. Moreover, our patient had a medical history of good health with only minor health issues that included hypertension and osteoporosis. However, prior to hospital admission, she had recently experienced two severe headache attacks; the last episode was accompanied by nausea, vomiting and blurred vision. Hyponatremia (120 mEq/L) with low serum osmolality (247 mOsm/L) and highly elevated urine osmolality (695 mOsm/L) were detected. An endocrinological investigation revealed hypocortisolism with no other hormone disturbances. Fundoscopy showed no pathological findings. However, further ophthalmologic examination with Goldman perimetry confirmed a bitemporal hemianopsia accentuated on her right side. Her neurological examination results were otherwise normal. After substitution therapy with hydrocortisone, our patient rapidly improved and her headaches subsided.\nFindings from a magnetic resonance imaging (MRI) scan were suggestive of an acute hemorrhage of the sellar process, consistent with pituitary apoplexy . Except for an age-consistent vascular leukoencephalopathy, the diagnostic imaging showed no further pathological findings. Our tentative diagnosis at this point was a pituitary adenoma with pituitary apoplexy.\nDue to these clinical and radiological findings, the decision was made to surgically remove the tumor. A gross total extirpation using a transnasal, transsphenoidal approach to the pituitary mass was successfully performed. Intraoperatively, the tumor appeared yellowish-brown, was relatively firm and was located within a sellar hematoma cavity, which was evacuated.\nPostoperatively, our patient's visual field deficits improved markedly on clinical examination and Goldman perimetry confirmed a partial recovery of her bitemporal visual field deficits. Endocrinological studies showed panhypopituitarism with partial and transient diabetes insipidus. Our patient received substitution therapy with hydrocortisone, levothyroxine and transient therapy with desmopressin. Overall, our patient remained in good health with a satisfactory level of performance. A repeat MRI scan taken 16 months after surgery showed good chiasmatic decompression with no residual tumor mass .\nThe resected tumor was examined with light microscopy, which revealed a small, well circumscribed, non-adenomatous tumor surrounded by slightly compressed remnants of adenohypophyseal parenchyma . The tumor was richly vascularized with an observable reticular mesh of thin-walled capillaries interspersed with large epithelioid-looking cells . Pale eosinophilic cytoplasm showed xanthomatous or vacuolar change . Immunohistochemistry confirmed the expression of the endothelial-associated markers CD31 and CD34 in the intratumoral capillaries, although not in the stromal cells themselves. Conversely, the stromal cells were diffusely immunoreactive for vimentin, with a minority of cells also coexpressing S100 protein and epithelial membrane antigen . No inflammatory infiltrate was detected except for the occasional mast cell . Staining for cytokeratins tested negative, as did the Langerhans-cell-associated marker CD1a. Less than 1% of lesional cell nuclei were labeled with the cell proliferation-associated antigen Ki-67.\nGiven the above findings, we identified the tumor as an intrapituitary example of capillary hemangioblastoma (World Health Organization grade I). Since our patient displayed no clinical stigmata of VHL disease, genetic testing was not performed.", + "fulltext_subclaims": [ + "The patient was an 80-year-old Caucasian woman.", + "The patient had a 12-year history of an endocrine inactive steady sellar mass lesion.", + "The sellar mass lesion was 13 mm in diameter.", + "The patient had been previously asymptomatic.", + "The patient had no pituitary hormone deficiency.", + "The patient had no visual impairments.", + "The patient had a medical history of hypertension.", + "The patient had a medical history of osteoporosis.", + "The patient had recently experienced two severe headache attacks.", + "The last headache episode was accompanied by nausea.", + "The last headache episode was accompanied by vomiting.", + "The last headache episode was accompanied by blurred vision.", + "Hyponatremia (120 mEq/L) was detected.", + "Low serum osmolality (247 mOsm/L) was detected.", + "Highly elevated urine osmolality (695 mOsm/L) was detected.", + "An endocrinological investigation revealed hypocortisolism.", + "No other hormone disturbances were found.", + "Fundoscopy showed no pathological findings.", + "Goldman perimetry confirmed a bitemporal hemianopsia.", + "The bitemporal hemianopsia was accentuated on the right side.", + "The neurological examination results were otherwise normal.", + "Substitution therapy with hydrocortisone was initiated.", + "The patient rapidly improved after hydrocortisone therapy.", + "The headaches subsided after hydrocortisone therapy.", + "Findings from an MRI scan were suggestive of an acute hemorrhage of the sellar process.", + "The MRI findings were consistent with pituitary apoplexy.", + "Except for an age-consistent vascular leukoencephalopathy, no further pathological findings were seen on diagnostic imaging.", + "The tentative diagnosis was a pituitary adenoma with pituitary apoplexy.", + "The decision was made to surgically remove the tumor.", + "A gross total extirpation using a transnasal, transsphenoidal approach was performed.", + "Intraoperatively, the tumor appeared yellowish-brown.", + "The tumor was relatively firm.", + "The tumor was located within a sellar hematoma cavity.", + "The sellar hematoma cavity was evacuated.", + "Postoperatively, the patient's visual field deficits improved markedly.", + "Goldman perimetry confirmed a partial recovery of bitemporal visual field deficits.", + "Endocrinological studies showed panhypopituitarism.", + "Endocrinological studies showed partial and transient diabetes insipidus.", + "The patient received substitution therapy with hydrocortisone.", + "The patient received substitution therapy with levothyroxine.", + "The patient received transient therapy with desmopressin.", + "A repeat MRI scan taken 16 months after surgery showed good chiasmatic decompression.", + "The repeat MRI scan showed no residual tumor mass.", + "Light microscopy revealed a small, well circumscribed, non-adenomatous tumor.", + "The tumor was surrounded by slightly compressed remnants of adenohypophyseal parenchyma.", + "The tumor was richly vascularized with an observable reticular mesh of thin-walled capillaries.", + "The tumor contained large epithelioid-looking cells.", + "The pale eosinophilic cytoplasm showed xanthomatous or vacuolar change.", + "Immunohistochemistry confirmed the expression of CD31 in the intratumoral capillaries.", + "Immunohistochemistry confirmed the expression of CD34 in the intratumoral capillaries.", + "The stromal cells were diffusely immunoreactive for vimentin.", + "A minority of stromal cells coexpressed S100 protein.", + "A minority of stromal cells coexpressed epithelial membrane antigen.", + "No inflammatory infiltrate was detected except for the occasional mast cell.", + "Staining for cytokeratins tested negative.", + "Staining for CD1a tested negative.", + "Less than 1% of lesional cell nuclei were labeled with Ki-67.", + "The tumor was identified as an intrapituitary example of capillary hemangioblastoma.", + "The tumor was classified as World Health Organization grade I.", + "The patient displayed no clinical stigmata of VHL disease.", + "Genetic testing was not performed." + ], + "summary": "An 80-year-old, otherwise healthy Caucasian woman presented to our facility with severe headache attacks, hypocortisolism and blurred vision. A magnetic resonance imaging scan showed an acute hemorrhage of a known, stable and asymptomatic sellar mass lesion with chiasmatic compression accounting for our patient's acute visual impairment. The tumor was resected by a transnasal, transsphenoidal approach and histological examination revealed a capillary hemangioblastoma (World Health Organization grade I). Our patient recovered well and substitutional therapy was started for panhypopituitarism. A follow-up magnetic resonance imaging scan performed 16 months postoperatively showed good chiasmatic decompression with no tumor recurrence.", + "summary_subclaims": [ + "The patient is an 80-year-old, otherwise healthy Caucasian woman.", + "She presented with severe headache attacks.", + "She had hypocortisolism.", + "She had blurred vision.", + "A magnetic resonance imaging scan showed an acute hemorrhage of a known, stable and asymptomatic sellar mass lesion.", + "The mass lesion caused chiasmatic compression.", + "The tumor was resected by a transnasal, transsphenoidal approach.", + "Histological examination revealed a capillary hemangioblastoma.", + "The capillary hemangioblastoma was World Health Organization grade I.", + "Substitutional therapy was started for panhypopituitarism.", + "A follow-up magnetic resonance imaging scan was performed 16 months postoperatively.", + "The follow-up scan showed good chiasmatic decompression.", + "The follow-up scan showed no tumor recurrence." + ] + }, + { + "id": "multiclinsum_test_2531_en.txt", + "fulltext": "A 72-year-old Japanese woman with a 10-year history of T2DM had symptoms of diarrhea and persistent pain in left lower abdomen for 2 days and visited the emergency room in Kawasaki Medical School. She had an approximately 10-year history of hypertension and dyslipidemia. At that time, she was taking 4 mg/day of benidipine hydrochloride and 20 mg/day of azilsartan for the treatment of hypertension, and 25 mg/day of alogliptin and 500 mg/day of metformin for T2DM, and 2.5 mg/day of rosuvastatin for dyslipidemia. She had no remarkable family history. She was a housewife and she did not smoke tobacco or drink alcohol. She had no past history of digestive disease or obstetrics and gynecology disease. She had mild tenderness to palpation in her abdomen. Her height and body weight were 150.0 cm and 69.5 kg, respectively. Her vital signs were as follows: blood pressure 150/87 mmHg, heart rate 110 beats/minute, and temperature 36.4 °C. Inflammation markers were markedly elevated: white blood cell (WBC), 20,110/μL (neutrophil, 89.0%); C-reactive protein (CRP), 16.12 mg/dL. Anemia and mild hypoalbuminemia were observed although their causes remained unknown: red blood cell, 304 × 104/μL; hemoglobin (Hb), 9.3 g/dL; total protein (TP), 6.8 g/dL; and albumin (Alb), 3.2 g/dL. Her liver and renal function were within normal range as follows: aspartate aminotransferase (AST), 14 U/L; alanine aminotransferase (ALT), 9 U/L; gamma-glutamyl transpeptidase (γ-GTP), 8 U/L; lactate dehydrogenase (LDH), 202 U/L; creatinine (Cre), 0.81 mg/dL; blood urea nitrogen (BUN), 7 mg/dL; Na, 134 mEq/L; K, 3.8 mEq/L; Cl, 99 mEq/L; Cre clearance, 66.9 mL/minute; and urinary Alb, 15.1 mg/g·Cr. As shown in Fig. , her abdominal computed tomography (CT) on admission revealed a large tumor with calcification in left side of intrapelvis (upper middle panel) which was not observed in abdominal CT 1 year before (upper left panel). She had abdominal CT 1 year before by a urologist because bladder diverticulum was suspected at an annual medical checkup with abdominal ultrasonography. The tumor size was as large as 65 mm in diameter. In addition, as shown in Fig. , MRI showed a large tumor in left side of intrapelvis at the same lesion site observed in CT. An axial T1-weighted (T1W) image through the pelvis showed a markedly dilated fallopian tube posterior to the left ovary (upper left panel). Axial T2-weighted (T2W) image showed a slightly higher intensity (upper right panel). Axial diffusion-weighted (DW) image and contrast-enhanced T1W image showed a high intensity lesion at the same place (lower left and right panels). Based on these findings, we finally diagnosed her as having pyosalpinx.\nOn admission, she had symptoms of diarrhea and persistent pain in left lower abdomen, but there were no findings in physical and neurological examinations. Her glycemic control was relatively good: HbA1c, 6.6%; glycoalbumin, 23.6%. In addition, her HbA1c levels were around 6% for over 1 year with the medication (metformin 500 mg, alogliptin 25 mg). However, during the acute phase of infection, we treated her with intensive insulin therapy using insulin aspart and insulin glargine. Tumor makers were within normal range: carcinoembryonic antigen (CEA), < 1.0 ng/mL; cancer antigen (CA) 19-9, 6.0 U/mL; and CA-125, 11.0 U/mL. Pathogenic bacteria were not detected. Her Treponema pallidum hemagglutination (TPHA) was positive but rapid plasma reagin (RPR) for Treponema pallidum was negative. Candida antigen and β-D-glucan were negative. Neisseria gonorrhoeae deoxyribonucleic acid (DNA) and Chlamydia trachomatis DNA in the urine were negative. Although pathogenic bacteria were not detected, we started antibiotics therapy for pyosalpinx (13.5 g/day of tazobactam/piperacillin and 500 mg/day of levofloxacin) . We discussed the necessity of surgery such as laparoscopy with gynecologists, but finally we selected antibiotics therapy without laparoscopy because her symptoms and laboratory data were very much improved. Her laboratory data 14 days after starting the antibiotics were improved and became within normal range (WBC, 5500/μL (neutrophil 47.4%); CRP, 0.04 mg/dl); we stopped antibiotics . Laboratory data were within normal range even after stopping antibiotics. T2DM was well controlled with orally administered anti-diabetes drugs (metformin 500 mg, alogliptin 25 mg, and gliclazide 10 mg): HbA1c, 6.0%; glycoalbumin, 16.5%. The tumor gradually reduced in size: 25 days later (upper right panel, Fig. ), 3 months later (lower left panel, Fig. ), and 6 months later (lower middle panel, Fig. ) compared to that on admission (upper middle panel, Fig. ); however, the tumor did not disappear completely even 6 months later. Finally she was discharged without any symptoms and/or problems. After discharge, she had no symptoms and/or problems, and her inflammation markers remained within normal levels for at least 6 months.", + "fulltext_subclaims": [ + "The patient is a 72-year-old Japanese woman.", + "She has a 10-year history of T2DM.", + "She had symptoms of diarrhea and persistent pain in left lower abdomen for 2 days.", + "She visited the emergency room in Kawasaki Medical School.", + "She had an approximately 10-year history of hypertension.", + "She had a history of dyslipidemia.", + "She was taking 4 mg/day of benidipine hydrochloride for hypertension.", + "She was taking 20 mg/day of azilsartan for hypertension.", + "She was taking 25 mg/day of alogliptin for T2DM.", + "She was taking 500 mg/day of metformin for T2DM.", + "She was taking 2.5 mg/day of rosuvastatin for dyslipidemia.", + "She had no remarkable family history.", + "She did not smoke tobacco.", + "She did not drink alcohol.", + "She had no past history of digestive disease.", + "She had no past history of obstetrics and gynecology disease.", + "She had mild tenderness to palpation in her abdomen.", + "Her height was 150.0 cm.", + "Her body weight was 69.5 kg.", + "Her blood pressure was 150/87 mmHg.", + "Her heart rate was 110 beats/minute.", + "Her temperature was 36.4 °C.", + "Her white blood cell count was 20,110/μL.", + "Her neutrophil percentage was 89.0%.", + "Her C-reactive protein was 16.12 mg/dL.", + "Her hemoglobin was 9.3 g/dL.", + "Her albumin was 3.2 g/dL.", + "Her abdominal CT on admission revealed a large tumor with calcification in the left side of the intrapelvis.", + "The tumor was not observed in abdominal CT 1 year before.", + "The tumor size was as large as 65 mm in diameter.", + "MRI showed a large tumor in the left side of the intrapelvis.", + "An axial T1-weighted image showed a markedly dilated fallopian tube posterior to the left ovary.", + "Axial T2-weighted image showed a slightly higher intensity.", + "Axial diffusion-weighted image showed a high intensity lesion.", + "Contrast-enhanced T1-weighted image showed a high intensity lesion.", + "The final diagnosis was pyosalpinx.", + "Her HbA1c was 6.6%.", + "Her HbA1c levels were around 6% for over 1 year with the medication.", + "During the acute phase of infection, she was treated with intensive insulin therapy using insulin aspart and insulin glargine.", + "Her carcinoembryonic antigen was < 1.0 ng/mL.", + "Her cancer antigen 19-9 was 6.0 U/mL.", + "Her cancer antigen 125 was 11.0 U/mL.", + "Pathogenic bacteria were not detected.", + "Her Treponema pallidum hemagglutination was positive.", + "Her rapid plasma reagin for Treponema pallidum was negative.", + "Candida antigen was negative.", + "β-D-glucan was negative.", + "Neisseria gonorrhoeae DNA in the urine was negative.", + "Chlamydia trachomatis DNA in the urine was negative.", + "Antibiotics therapy for pyosalpinx was started with 13.5 g/day of tazobactam/piperacillin and 500 mg/day of levofloxacin.", + "Antibiotics therapy was selected without laparoscopy.", + "Her laboratory data were improved and within normal range 14 days after starting antibiotics.", + "Antibiotics were stopped after 14 days.", + "Her tumor gradually reduced in size over 25 days.", + "Her tumor continued to reduce in size over 3 months.", + "Her tumor continued to reduce in size over 6 months.", + "The tumor did not disappear completely even 6 months later.", + "She was discharged without any symptoms and/or problems.", + "After discharge, she had no symptoms and/or problems.", + "Her inflammation markers remained within normal levels for at least 6 months." + ], + "summary": "We experienced a rare case of large pyosalpinx in an elderly patient with well-controlled type 2 diabetes mellitus. A 72-year-old Japanese woman with a 10-year history of type 2 diabetes mellitus had symptoms of diarrhea and persistent pain in left lower abdomen. She had mild tenderness to palpation in her abdomen. Inflammation markers were markedly elevated. Her abdominal computed tomography and magnetic resonance imaging on admission revealed a tumor in left side of intrapelvis and we diagnosed her as having pyosalpinx. Pathogenic bacteria were not detected. On admission, her glycemic control was relatively good; in addition, her glycated hemoglobin levels were around 6% for over 1 year. Although pathogenic bacteria were not detected, we started antibiotics therapy. Fourteen days after starting the antibiotics her laboratory data were improved. Three months later, the tumor was markedly smaller compared to that on admission.", + "summary_subclaims": [ + "We experienced a rare case of large pyosalpinx in an elderly patient with well-controlled type 2 diabetes mellitus.", + "The patient was a 72-year-old Japanese woman.", + "She had a 10-year history of type 2 diabetes mellitus.", + "She had symptoms of diarrhea and persistent pain in left lower abdomen.", + "She had mild tenderness to palpation in her abdomen.", + "Inflammation markers were markedly elevated.", + "Abdominal computed tomography and magnetic resonance imaging on admission revealed a tumor in left side of intrapelvis.", + "We diagnosed her as having pyosalpinx.", + "Pathogenic bacteria were not detected.", + "On admission, her glycated hemoglobin levels were around 6% for over 1 year.", + "Although pathogenic bacteria were not detected, we started antibiotics therapy.", + "Fourteen days after starting the antibiotics her laboratory data were improved.", + "Three months later, the tumor was markedly smaller compared to that on admission." + ] + }, + { + "id": "multiclinsum_test_2931_en.txt", + "fulltext": "A 56-year-old male with a past medical history of alcohol substance abuse with seizures, hypertension, and tobacco abuse presented to our urban Level I trauma center after falling from a ladder. He presented with left shoulder, elbow, and chest pain. Radiographs demonstrated displaced 3-part proximal humerus fracture ( and ). In addition, the patient was found to have a non-displaced ipsilateral radial neck fracture and ipsilateral non-displaced 4th–9th rib fractures.\nOperative management of the injury occurred the following day. An anterolateral deltoid splitting approach was used, and the fracture was identified and reduced. A fibular strut allograft (LifeNet Health, Virginia Beach, VA.) was inserted into the humeral canal to augment the fixation. Fracture fixation was performed with a DePuy Synthes (West Chester, PA) 3.5 mm locking compression plate (LCP) proximal humerus plate ( and ). The greater and lesser tuberosities and associated rotator cuff muscles were sutured down to the plate using large non-absorbable suture. Total operative time was 75 min, and the estimated blood loss was minimal. The patient was then transferred to the post anesthesia care unit (PACU). There were no perioperative complications.\nThe patient was immobilized with a sling and instructed to be non-weight bearing. The patient was able to be range of motion as tolerated to his left upper extremity. The additional injuries were treated nonoperatively. The patient was discharged on post-operative day 5.\nOn post-operative day 11, the patient presented again to our trauma center after a fall down multiple stairs while intoxicated. The patient presented with the left shoulder pain, back pain, and left chest wall pain. The previous surgical incision showed routine healing. Radiographs demonstrated a displaced peri-implant proximal humerus fracture just distal to his original fracture fixation ( and ). In addition, the patient was found to have multiple vertebral superior endplate fractures.\nOperative management of the injury occurred the following day. The same anterolateral deltoid splitting approach was used and extended into the anterolateral approach to the humerus. The peri-implant humeral shaft fracture was first reduced and provisionally held together with two separate lag screws. Then, the distal two screws from the proximal humerus plate were removed. A DePuy synthes (West Chester, PA) 10 hole 3.5 mm LCP metaphyseal plate with a thin proximal flare was placed so that the two most proximal screws were overlapped to link the two constructs (-). The greater tuberosity fragment had displaced from the fall and was fixed with an independent lag screw and an additional heavy gauge non-absorbable suture. Two proximal screws that were loosened from the fall were also replaced ( and ). Total operative time was 72 min, and the estimated blood loss was minimal. The patient was then transferred to the PACU. There were no perioperative complications.\nThe patient was immobilized with a sling and instructed to be non-weight-bearing. The patient was able to be range of motion as tolerated to his left upper extremity. The additional injuries were treated nonoperatively. The patient was discharged on post-operative day 1.\nThe patient followed up at 2 weeks postoperatively with a well healing incision and no complications. The patient had full passive range of motion, decreased active range of motion secondary to pain, and was otherwise neurovascularly intact. The patient was then lost to follow-up until 13 months postoperatively when he presented for repeat clinical evaluation. Clinically, the patient had no complications with full strength and range of motion. The patient reported very minimal pain and was not using pain medication. Radiographs at this final visit demonstrated stacked plate fixation with appropriate positioning, evidence of bony union, and no signs of displacement or hardware loosening. The patient was able to return to his previous level of activity.", + "fulltext_subclaims": [ + "The patient is a 56-year-old male.", + "The patient has a past medical history of alcohol substance abuse with seizures.", + "The patient has a past medical history of hypertension.", + "The patient has a past medical history of tobacco abuse.", + "The patient presented after falling from a ladder.", + "The patient had left shoulder pain.", + "The patient had left elbow pain.", + "The patient had chest pain.", + "Radiographs demonstrated a displaced 3-part proximal humerus fracture.", + "The patient had a non-displaced ipsilateral radial neck fracture.", + "The patient had ipsilateral non-displaced 4th–9th rib fractures.", + "Operative management of the injury occurred the following day.", + "An anterolateral deltoid splitting approach was used.", + "A fibular strut allograft from LifeNet Health was inserted into the humeral canal.", + "Fracture fixation was performed with a DePuy Synthes 3.5 mm locking compression plate.", + "The greater and lesser tuberosities and associated rotator cuff muscles were sutured down to the plate.", + "Total operative time was 75 minutes.", + "Estimated blood loss was minimal.", + "There were no perioperative complications.", + "The patient was immobilized with a sling.", + "The patient was instructed to be non-weight bearing.", + "The patient was able to range of motion as tolerated.", + "The additional injuries were treated nonoperatively.", + "The patient was discharged on post-operative day 5.", + "On post-operative day 11, the patient presented after a fall down multiple stairs.", + "The patient was intoxicated at the time of the fall.", + "The patient had left shoulder pain.", + "The patient had back pain.", + "The patient had left chest wall pain.", + "Radiographs demonstrated a displaced peri-implant proximal humerus fracture.", + "The patient had multiple vertebral superior endplate fractures.", + "Operative management of the injury occurred the following day.", + "The same anterolateral deltoid splitting approach was used.", + "The approach was extended into the anterolateral approach to the humerus.", + "The peri-implant humeral shaft fracture was reduced.", + "The distal two screws from the proximal humerus plate were removed.", + "A DePuy Synthes 10 hole 3.5 mm LCP metaphyseal plate was placed.", + "The greater tuberosity fragment had displaced from the fall.", + "The greater tuberosity fragment was fixed with an independent lag screw.", + "Two proximal screws that were loosened from the fall were replaced.", + "Total operative time was 72 minutes.", + "Estimated blood loss was minimal.", + "There were no perioperative complications.", + "The patient was immobilized with a sling.", + "The patient was instructed to be non-weight-bearing.", + "The patient was able to range of motion as tolerated.", + "The additional injuries were treated nonoperatively.", + "The patient was discharged on post-operative day 1.", + "The patient followed up at 2 weeks postoperatively.", + "The patient had full passive range of motion.", + "The patient had decreased active range of motion secondary to pain.", + "The patient was neurovascularly intact.", + "The patient was lost to follow-up until 13 months postoperatively.", + "The patient had no complications.", + "The patient had full strength.", + "The patient had full range of motion.", + "The patient reported very minimal pain.", + "The patient was not using pain medication.", + "Radiographs demonstrated stacked plate fixation with appropriate positioning.", + "Radiographs demonstrated evidence of bony union.", + "Radiographs showed no signs of displacement or hardware loosening.", + "The patient was able to return to his previous level of activity." + ], + "summary": "A 56-year-old male sustained a peri-implant proximal humerus fracture after undergoing ORIF. We present a stacked plating method for fixation of this injury. This construct allows for decreased operative time, less soft-tissue dissection, and the ability to leave previous intact hardware in place.", + "summary_subclaims": [ + "The patient is a 56-year-old male.", + "The patient sustained a peri-implant proximal humerus fracture.", + "The patient had previously undergone ORIF.", + "A stacked plating method was used for fixation.", + "The stacked plating method allows for decreased operative time.", + "The stacked plating method allows for less soft-tissue dissection.", + "The stacked plating method allows the ability to leave previous intact hardware in place." + ] + }, + { + "id": "multiclinsum_test_665_en.txt", + "fulltext": "A 25-year-old female health-care worker from central India, known SCD on folic acid and hydroxyurea, was admitted to our hospital 1 year back with complaints of fever and pain in the abdomen. She was diagnosed as a case of dengue, for which she was admitted under a physician. During the hospital course, her blood parameters revealed thrombocytopenia and blood culture showed growth of Klebsiella (all sickle cell patients are susceptible to capsulated organisms such as pneumococcus, Klebsiella, hemophilus due to functional asplenia, the patient did not receive any steroids during her hospitalization for dengue). She was then managed with a transfusion of platelets and blood products and was started on IV antibiotics injection Ceftriaxone + Tazobactam 8 hourly for 3 days, following which she showed improvement and was shifted to, oral doses of Cefixime 200 mg + Dicloxacillin 500 mg that were given for a week and was discharged.\nFollowing an asymptomatic period of 2 weeks, the patient presented with pain over the bilateral forearm and legs. On examination, there was local warmth and bony tenderness at the right forearm, no local discharging sinus, and no clinical evidence of a subcutaneous collection.\nOn evaluation, the plain radiological features were suggestive of periosteal changes and lytic lesions-osteomyelitis, although, the uniqueness of presentation of her symptoms was “Multifocal Bilaterally symmetrical involvement.” Laboratory evaluations were remarkable for leukocytosis with a white blood cell count of 18.4 × 103 (6.0–17.5) and C-reactive protein of 35 mg/dL.\nDifferential diagnosis of the presenting condition was:\nChronic multifocal recurrent osteomyelitis (CMRO) Multifocal pyogenic osteomyelitis Vaso-occlusive crisis leading to multiple bone infarcts.\nFurther to confirm our diagnosis, the incisional bone biopsy by corticotomy and debridement of the lesion from the most symptomatic right forearm region (right ulna) was performed.\nThe culture of biopsy from right ulna showed the growth of Klebsiella sp. and was only sensitive to Co-trimoxazole.\nThe patient was started on co-trimoxazole, and she tolerated well and had a significant clinical improvement in the form of subsidence of pain, normalization of the blood counts along with the acute phase reactants. The antibiotic treatment was continued for 6 weeks, the patient was observed closely post-hospitalization, continued to recover well, and completed her antibiotic course without any issues. She has not had any more recurrences of osteomyelitis or other serious infections till 1-year follow-up ( and ).", + "fulltext_subclaims": [ + "The patient is a 25-year-old female health-care worker from central India.", + "She has sickle cell disease.", + "She was admitted to the hospital 1 year back with complaints of fever and pain in the abdomen.", + "She was diagnosed with dengue.", + "She was admitted under a physician.", + "Her blood parameters revealed thrombocytopenia.", + "Blood culture showed growth of Klebsiella.", + "All sickle cell patients are susceptible to capsulated organisms such as pneumococcus, Klebsiella, hemophilus due to functional asplenia.", + "The patient did not receive any steroids during her hospitalization for dengue.", + "She was managed with a transfusion of platelets and blood products.", + "She was started on IV antibiotics injection Ceftriaxone + Tazobactam 8 hourly for 3 days.", + "She showed improvement and was shifted to oral doses of Cefixime 200 mg + Dicloxacillin 500 mg.", + "She was discharged after a week.", + "Following an asymptomatic period of 2 weeks, the patient presented with pain over the bilateral forearm and legs.", + "On examination, there was local warmth and bony tenderness at the right forearm.", + "There was no local discharging sinus.", + "There was no clinical evidence of a subcutaneous collection.", + "Plain radiological features were suggestive of periosteal changes and lytic lesions.", + "The uniqueness of presentation of her symptoms was 'Multifocal Bilaterally symmetrical involvement.'", + "The white blood cell count was 18.4 × 103.", + "The C-reactive protein was 35 mg/dL.", + "Differential diagnosis included chronic multifocal recurrent osteomyelitis.", + "Differential diagnosis included multifocal pyogenic osteomyelitis.", + "Differential diagnosis included vaso-occlusive crisis leading to multiple bone infarcts.", + "An incisional bone biopsy by corticotomy and debridement of the lesion from the right forearm region (right ulna) was performed.", + "The culture of biopsy from right ulna showed the growth of Klebsiella sp.", + "The organism was only sensitive to Co-trimoxazole.", + "The patient was started on co-trimoxazole.", + "She tolerated the treatment well.", + "She had a significant clinical improvement in the form of subsidence of pain.", + "She had normalization of the blood counts.", + "She had normalization of the acute phase reactants.", + "The antibiotic treatment was continued for 6 weeks.", + "The patient was observed closely post-hospitalization.", + "She continued to recover well.", + "She completed her antibiotic course without any issues.", + "She has not had any more recurrences of osteomyelitis or other serious infections till 1-year follow-up." + ], + "summary": "A 25-year-old female known SCD since childhood who underwent treatment for dengue at our hospital had her blood cultures positive for Klebsiella, following which she was treated with appropriate antibiotics. Two weeks following the asymptomatic period patient presented with complaints of pain over the bilateral forearm and legs. The patient was evaluated for laboratory parameters and plain radiograph of the bilateral forearm and bilateral legs. The radiological features were suggestive of osteomyelitis, showing \"Bilaterally symmetrical involvement.\" Laboratory parameters erythrocyte sedimentation rate (ESR) and C-reactive protein (CRP) were found raised. The patient was planned for biopsy and debridement of the lesion from the right ulna. The culture from the biopsy showed growth of Klebsiella sp. and was sensitive to co-trimoxazole. The patient was started on co-trimoxazole for 6 weeks and had a significant clinical improvement in the form of subsidence of pain, normalization of the blood counts along with the acute phase reactants (ESR, CRP).", + "summary_subclaims": [ + "The patient is a 25-year-old female.", + "The patient has sickle cell disease (SCD) since childhood.", + "The patient had treatment for dengue at the hospital.", + "Blood cultures were positive for Klebsiella.", + "The patient was treated with appropriate antibiotics.", + "Two weeks after an asymptomatic period, the patient presented with pain over the bilateral forearm and legs.", + "The patient had a plain radiograph of the bilateral forearm and bilateral legs.", + "The radiological features were suggestive of osteomyelitis.", + "The radiological features showed 'Bilaterally symmetrical involvement.'", + "Erythrocyte sedimentation rate (ESR) was found raised.", + "C-reactive protein (CRP) was found raised.", + "The patient was planned for biopsy and debridement of the lesion from the right ulna.", + "The culture from the biopsy showed growth of Klebsiella sp.", + "The culture was sensitive to co-trimoxazole.", + "The patient was started on co-trimoxazole for 6 weeks.", + "The patient had a significant clinical improvement.", + "The improvement included subsidence of pain.", + "The improvement included normalization of blood counts.", + "The improvement included normalization of acute phase reactants (ESR, CRP)." + ] + }, + { + "id": "multiclinsum_test_1333_en.txt", + "fulltext": "A 67-year-old man was referred for uncontrolled increased IOP in his left eye despite maximal tolerated medical therapy. He had previously been diagnosed with left secondary glaucoma related to idiopathic uveitis, which was diagnosed based on negative results in all systemic work-ups including serologic, radiologic test. His previous ocular history included laser iridotomy (LI) and trabeculectomy, which were performed three years prior to SLT procedure, as well as phacoemulsification with in-the-bag posterior chamber lens implantation which performed two years ago. His past medical history was unremarkable. Best corrected visual acuity was 20/20 in his right eye and 6/20 in his left eye. IOP measured by Goldmann applanation tonometry was 15 mmHg in his right eye and 28 mmHg in his left eye, with the latter being treated with a fixed combination of dorzolamide and timolol (Cosopt, MSD, Switzerland) twice daily, brimonidine 0.2% (Alphagan, Allergan, USA) twice daily and latanoprost 0.005% (Xalatan, Pfizer, Belgium) once nightly. Slit lamp examination showed deep anterior chambers in both eyes, as well as showing a shallow bleb, a patent LI hole at the 11 o’clock position of the iris, and an iridectomy site at the 12 o’clock position of the iris in the left eye. Gonioscopic examination of the left eye revealed peripheral anterior synechiae around the iridectomy site at the 12 o’clock position and hyperpigmented tissue within the trabecular meshwork in all quadrants . The patient was prescribed oral acetazolamide (Acetazol tab. 250 mg, Hanlim Pharm., Korea) twice daily for 1 week, reducing the IOP in his left eye to 17 mmHg as measured by Goldmann tonometry. Owing to drowsiness, however, the oral drug had to be discontinued. One week after discontinuing oral acetazolamide, the IOP returned to 30 mmHg. Therefore, it was decided to perform SLT while maintaining twice daily dosing of oral acetazolamide. SLT, rather than additional glaucoma surgery, was selected to reduce IOP because of following findings suggesting advanced glaucoma in the left eye , (1) a pale disc on fundus examination, (2) diffuse retinal nerve fiber layer (RNFL) loss on optical coherence tomography (OCT), and (3) severe field constriction on Humphrey visual field test .\nProparacaine topical anesthetic solution was applied to the left eye, and hydroxypropyl methylcellulose (Hycell solution 2%, Samil Pharm Co., Ltd., Korea) was used with the gonioscopy lens. SLT was performed with 107 shots treating 360° of the trabecular meshwork with 1.1 mJ, which falls within the typical power range of 0.4–1.4 mJ . Thirty minutes after the treatment, the IOP in the left eye was 17 mmHg. The patient was instructed to apply fluorometholone acetate 0.1% (Flarex, Novartis Pharm., Switzerland) drops four times per day for 3 days and to return in a week for follow-up.\nOne week after the procedure, the IOP in the left eye was 7 mmHg and there were no other symptoms other than foreign body sensation in the eye. Significant anterior chamber shallowing and inflammation were also not observed. Considering that the IOP decreased sufficiently, oral acetazolamide was discontinued and the patient followed-up 2 weeks later. At that visit, the patient reported ocular pain in the left eye when touched. The best corrected visual acuity and IOP of the left eye were 3/20 and 4 mmHg, respectively. Slit lamp examination showed a deep anterior chamber without evidence of marked inflammation. Fundus examination and B-scan ultrasonography revealed hypotonic maculopathy and choroidal detachment in the left eye .\nAll anti-glaucomatous drugs were discontinued and the patient was started on oral prednisolone acetate (Solondo tab, Yuhanmedica, Korea) 30 mg per day. One week later, the IOP in the left eye was 4 mmHg, and the choroidal detachment did not improve. The patient was therefore started on additional atropine 1% (Isopto atropine, Alcon, USA) twice daily and prednisolone acetate suspension (Pred Forte 1%, Allergan, USA) four times daily. The IOP in his left eye was 7 mmHg 3 days later and 23 mmHg 10 days later, and the choroidal detachment had improved . One week after discontinuation of oral prednisolone acetate, atropine eye drops, and prednisolone acetate suspension, the IOP in his left eye was stable at 8 mmHg. Three months after SLT, the IOP in that eye was well maintained at 10 mmHg, with the patient being treated with only one anti-glaucomatous drug, brimonidine.", + "fulltext_subclaims": [ + "The patient was referred for uncontrolled increased IOP in his left eye despite maximal tolerated medical therapy.", + "He had previously been diagnosed with left secondary glaucoma related to idiopathic uveitis.", + "The diagnosis of idiopathic uveitis was based on negative results in all systemic work-ups including serologic and radiologic tests.", + "His previous ocular history included laser iridotomy and trabeculectomy, performed three years prior to SLT.", + "He had undergone phacoemulsification with in-the-bag posterior chamber lens implantation two years ago.", + "Best corrected visual acuity was 20/20 in his right eye and 6/20 in his left eye.", + "IOP measured by Goldmann applanation tonometry was 15 mmHg in his right eye and 28 mmHg in his left eye.", + "The left eye was treated with a fixed combination of dorzolamide and timolol twice daily.", + "The left eye was also treated with brimonidine 0.2% twice daily.", + "The left eye was treated with latanoprost 0.005% once nightly.", + "Slit lamp examination showed a shallow bleb in the left eye.", + "Gonioscopic examination of the left eye revealed peripheral anterior synechiae around the iridectomy site at the 12 o’clock position.", + "The patient was prescribed oral acetazolamide twice daily for 1 week.", + "Oral acetazolamide reduced the IOP in his left eye to 17 mmHg as measured by Goldmann tonometry.", + "The oral drug had to be discontinued due to drowsiness.", + "One week after discontinuing oral acetazolamide, the IOP returned to 30 mmHg.", + "It was decided to perform SLT while maintaining twice daily dosing of oral acetazolamide.", + "SLT was selected because of findings suggesting advanced glaucoma in the left eye.", + "SLT was performed with 107 shots treating 360° of the trabecular meshwork with 1.1 mJ.", + "The power used during SLT fell within the typical power range of 0.4–1.4 mJ.", + "Thirty minutes after the treatment, the IOP in the left eye was 17 mmHg.", + "The patient was instructed to apply fluorometholone acetate 0.1% drops four times per day for 3 days.", + "One week after the procedure, the IOP in the left eye was 7 mmHg.", + "There were no other symptoms other than foreign body sensation in the eye.", + "Significant anterior chamber shallowing and inflammation were also not observed.", + "Considering that the IOP decreased sufficiently, oral acetazolamide was discontinued.", + "At the 2-week follow-up, the patient reported ocular pain in the left eye when touched.", + "The best corrected visual acuity of the left eye was 3/20.", + "The IOP of the left eye was 4 mmHg.", + "Fundus examination and B-scan ultrasonography revealed hypotonic maculopathy and choroidal detachment in the left eye.", + "All anti-glaucomatous drugs were discontinued.", + "The patient was started on oral prednisolone acetate 30 mg per day.", + "One week later, the IOP in the left eye was 4 mmHg.", + "The choroidal detachment did not improve.", + "The patient was started on additional atropine 1% twice daily.", + "The patient was started on prednisolone acetate suspension four times daily.", + "The IOP in his left eye was 7 mmHg 3 days later.", + "The IOP in his left eye was 23 mmHg 10 days later.", + "The choroidal detachment had improved.", + "One week after discontinuation of oral prednisolone acetate, atropine eye drops, and prednisolone acetate suspension, the IOP in his left eye was stable at 8 mmHg.", + "Three months after SLT, the IOP in that eye was well maintained at 10 mmHg.", + "The patient was being treated with only one anti-glaucomatous drug, brimonidine." + ], + "summary": "A 67-year-old man was referred for elevated IOP in his left eye with advanced glaucomatous visual field loss. He had previously been diagnosed with idiopathic uveitic glaucoma in the left eye, for which he underwent laser iridotomy, trabeculectomy, and cataract surgery. At the first visit, the IOP of his left eye measured by Goldmann tonometry was 28 mmHg despite maximally tolerated medical treatment. SLT was performed in his left eye, resulting in an IOP of 7 mmHg 7 days later. At 3 weeks post-procedure, the patient experienced ocular pain and decreased visual acuity in his left eye. Slit-lamp examination revealed deep anterior chamber depth and no inflammation reaction, but the IOP in his left eye was 4 mmHg, and both fundus and B-scan ultrasonography showed serous choroidal detachment. All anti-glaucoma agents were stopped, and the patient was started on treatment with oral prednisolone and cyclopentolate eye drops. Three weeks later, choroidal detachment had resolved and the IOP in his left eye had stabilized at 8 mmHg. Follow-up 3 months later showed that the IOP in his left eye remained stable.", + "summary_subclaims": [ + "The patient was a 67-year-old man.", + "He was referred for elevated IOP in his left eye.", + "He had advanced glaucomatous visual field loss.", + "He had previously been diagnosed with idiopathic uveitic glaucoma in the left eye.", + "He underwent laser iridotomy in the left eye.", + "He underwent trabeculectomy in the left eye.", + "He underwent cataract surgery in the left eye.", + "At the first visit, the IOP of his left eye measured by Goldmann tonometry was 28 mmHg.", + "The IOP was measured despite maximally tolerated medical treatment.", + "SLT was performed in his left eye.", + "The IOP in his left eye was 7 mmHg 7 days after SLT.", + "At 3 weeks post-procedure, the patient experienced ocular pain.", + "At 3 weeks post-procedure, the patient experienced decreased visual acuity in his left eye.", + "Slit-lamp examination revealed deep anterior chamber depth.", + "Slit-lamp examination revealed no inflammation reaction.", + "The IOP in his left eye was 4 mmHg at 3 weeks post-procedure.", + "Both fundus and B-scan ultrasonography showed serous choroidal detachment.", + "All anti-glaucoma agents were stopped.", + "The patient was started on treatment with oral prednisolone.", + "The patient was started on treatment with cyclopentolate eye drops.", + "Three weeks later, choroidal detachment had resolved.", + "The IOP in his left eye had stabilized at 8 mmHg three weeks later.", + "Follow-up 3 months later showed that the IOP in his left eye remained stable." + ] + }, + { + "id": "multiclinsum_test_1725_en.txt", + "fulltext": "The patient, a 39-year-old man with frequent urination, urgency and pain in the bladder area while holding back the urine for 1 month was in good health before. There was no abnormality in the urine routine. The examination of the prostatic fluid showed elevated white blood cells and decreased lecithin bodies. Prostatitis was initially diagnosed. After two weeks of treatment with cephalosporin and M receptor blocker, the symptoms of frequent urination and urgency were partially improved. Review the prostatic fluid indicated that the white blood cells were normal, and the lecithin bodies increased by 20% compared to 2 weeks ago, but the pain in the bladder area was not significantly relieved when the urine was held. Further examination of the urinary system color Doppler ultrasound suggest that the bladder had occupying space. An approximately 2.0 cm solid lesion in the left upper part of the pelvic cavity was seen by ultrasound . The admission-related examination, including blood, coagulation, liver function and kidney function tests as well as electrocardiogram and chest X-ray, showed no obvious abnormalities. CT suggested that a 2.0 × 1.9 cm mass was located in the left front wall of the bladder and was protruding outward with clear boundaries . There was no obvious abnormality of the bladder mucosa on cystoscopy. Nuclear heterogeneous cells were not detected in the urinary exfoliative cytology.\nWith the results of the imaging examination, a benign tumour was considered. Based on the tumour being convex to the outside of the bladder, a laparoscopic partial cystectomy through the extraperitoneal space was performed . After general anaesthesia, the patient was placed in the supine position with the buttocks raised by 10 cm. We selected a 3 cm midline incision under the umbilicus as the observation hole, cutting the skin, subcutaneous tissue and the anterior and posterior sheaths of the rectus abdominis layer by layer. Placing the balloon under the posterior rectus abdominis, the extraperitoneal space was expanded . We separated the adipose tissue on the anterior wall of the bladder. A mass, 2.0 × 2.0 cm in size with a smooth surface, was seen on the left anterior wall of the bladder and protruded outside of the bladder. Using an ultrasonic knife, the tumour was completely removed from the bladder with 0.5 cm normal bladder tissue margins . The bladder wall was sutured by using 1–0 absorbable barbed suture through continuous full-thickness . A total of 200 ml of normal saline was injected into the bladder through the catheter, and there was no fluid extravasation in the incision of the bladder wall, which confirmed that the suture was reliable. The operation lasted 65 min, and the intraoperative blood loss was approximately 20 ml. Pathological examination described that the bladder mass had a size of 2 × 2 × 1.6 cm, with a surface covering of bladder mucosa and an envelope with clear boundaries, while the cut surface was greyish white. A schwannoma with oedema and bleeding was considered by pathological diagnosis. We used Envision staining to detect the expression of biomarkers. Immunohistochemical staining showed: S100(+), Desmin(−), SMA(−), CD34(−), Ki67 (about 8%+) . The patient used a semi-liquid diet and walked after getting out of bed on the 1st day after surgery, without obvious gastrointestinal symptoms such as abdominal distension. The pelvic drainage tube was removed on the 4th day after surgery, and the catheter was removed on the 7th day after surgery. There was no recurrence after 2 years follow-up by cystoscopy and CT.", + "fulltext_subclaims": [ + "The patient is a 39-year-old man.", + "The patient had frequent urination, urgency, and pain in the bladder area while holding back urine for 1 month.", + "There was no abnormality in the urine routine.", + "The examination of the prostatic fluid showed elevated white blood cells.", + "The examination of the prostatic fluid showed decreased lecithin bodies.", + "Prostatitis was initially diagnosed.", + "After two weeks of treatment with cephalosporin and M receptor blocker, the symptoms of frequent urination and urgency were partially improved.", + "Review of the prostatic fluid indicated that the white blood cells were normal.", + "The lecithin bodies increased by 20% compared to 2 weeks ago.", + "The pain in the bladder area was not significantly relieved when the urine was held.", + "The urinary system color Doppler ultrasound suggested that the bladder had an occupying space.", + "An approximately 2.0 cm solid lesion in the left upper part of the pelvic cavity was seen by ultrasound.", + "The admission-related examination, including blood, coagulation, liver function and kidney function tests as well as electrocardiogram and chest X-ray, showed no obvious abnormalities.", + "CT suggested that a 2.0 × 1.9 cm mass was located in the left front wall of the bladder and was protruding outward with clear boundaries.", + "There was no obvious abnormality of the bladder mucosa on cystoscopy.", + "Nuclear heterogeneous cells were not detected in the urinary exfoliative cytology.", + "With the results of the imaging examination, a benign tumour was considered.", + "Based on the tumour being convex to the outside of the bladder, a laparoscopic partial cystectomy through the extraperitoneal space was performed.", + "After general anaesthesia, the patient was placed in the supine position with the buttocks raised by 10 cm.", + "A 3 cm midline incision under the umbilicus was selected as the observation hole.", + "The incision was made through the skin, subcutaneous tissue, and the anterior and posterior sheaths of the rectus abdominis.", + "Placing the balloon under the posterior rectus abdominis, the extraperitoneal space was expanded.", + "A mass, 2.0 × 2.0 cm in size with a smooth surface, was seen on the left anterior wall of the bladder and protruded outside of the bladder.", + "The tumour was completely removed from the bladder with 0.5 cm normal bladder tissue margins.", + "The bladder wall was sutured using 1–0 absorbable barbed suture through continuous full-thickness.", + "A total of 200 ml of normal saline was injected into the bladder through the catheter.", + "There was no fluid extravasation in the incision of the bladder wall.", + "The operation lasted 65 min.", + "The intraoperative blood loss was approximately 20 ml.", + "Pathological examination described that the bladder mass had a size of 2 × 2 × 1.6 cm.", + "The surface of the mass was covered with bladder mucosa.", + "The mass had an envelope with clear boundaries.", + "The cut surface was greyish white.", + "A schwannoma with oedema and bleeding was considered by pathological diagnosis.", + "Immunohistochemical staining showed: S100(+), Desmin(−), SMA(−), CD34(−), Ki67 (about 8%+).", + "The patient used a semi-liquid diet and walked after getting out of bed on the 1st day after surgery.", + "The patient had no obvious gastrointestinal symptoms such as abdominal distension.", + "The pelvic drainage tube was removed on the 4th day after surgery.", + "The catheter was removed on the 7th day after surgery.", + "There was no recurrence after 2 years follow-up by cystoscopy and CT." + ], + "summary": "A 39-year-old man had no significant improvement in symptoms due to frequent urination and urgency for 1 month following the treatment of prostatitis for 2 weeks. Ultrasound and computed tomography (CT) showed a mass in the left side wall of the bladder (size approximately 2.0 × 1.9 cm) that had clear boundaries and protruded outward from the bladder. After the extraperitoneal space was dilated with a balloon, a minimally invasive laparoscopic partial cystectomy was performed in this space to remove the tumour. The pathological diagnosis was bladder schwannoma. Immunohistochemical staining showed that it was strongly S100 protein positive. There was no recurrence after 2 years follow-up by cystoscopy and CT.", + "summary_subclaims": [ + "The patient is a 39-year-old man.", + "He had no significant improvement in symptoms.", + "His symptoms included frequent urination and urgency.", + "The symptoms had been present for 1 month.", + "He had been treated for prostatitis for 2 weeks.", + "Ultrasound and CT showed a mass in the left side wall of the bladder.", + "The mass was approximately 2.0 × 1.9 cm.", + "The mass had clear boundaries.", + "The mass protruded outward from the bladder.", + "The extraperitoneal space was dilated with a balloon.", + "A minimally invasive laparoscopic partial cystectomy was performed.", + "The tumour was removed.", + "The pathological diagnosis was bladder schwannoma.", + "Immunohistochemical staining showed it was strongly S100 protein positive.", + "There was no recurrence after 2 years follow-up.", + "Cystoscopy and CT were used for follow-up." + ] + }, + { + "id": "multiclinsum_test_2863_en.txt", + "fulltext": "A 3-year-old Arabic boy from Yemen presented with intermittent episodes of shortness of breath, lethargy, fatigability, vomiting, and \"cyanotic\" discoloration of his skin, lips, mucous membranes and nail beds for the past two years. He was thought to have methemoglobinemia due to persistent cyanosis. He was born in Yemen and moved to the USA for further treatment one year prior to his visit to our clinic. He was evaluated in several institutions in Yemen, Europe and the USA for these problems but no specific diagnosis was ever made. He had one maternal uncle who died suddenly at 35 years of age and 4 full siblings (all males) who died of unknown causes between 2 and 4 years of age. His deceased siblings had similar symptoms and discoloration of mucous membranes. None of them had autopsies. He had 4 other siblings (2 brothers and 2 sisters) who were alive with no medical problems. He had normal electrolytes, blood urea nitrogen (BUN) and creatinine (Cr) levels on several occasions. He had normal results for cardiac examination, echocardiogram, hematologic evaluation and hemoglobin electrophoresis.\nHe was referred to our center for further evaluation of his cyanosis. The result of his physical examination was normal, except for the noted discoloration of his lips and nail beds. His arterial blood showed mild hypoxemia as follows: pH 7.32, PaCO2 37.1 mmHg, PaO2 86 mmHg, and HCO3 18.9. His methemoglobin and carboxyhemoglobin levels were 1.10% and 0.3%, respectively. He had a previous chest X-ray during one of his prior admissions which was interpreted as normal. However, upon further examination of the film at our clinic, we identified a subtle parenchymal hyperlucency of a large part of his right mid-lung area . His chest computed tomography (CT) scan showed multiple cystic lesions in his right lung that was compatible with CPAM . CT scan of the abdomen showed no abnormalities of the adrenal glands, or other abdominal organs.\nBefore the surgical removal of his CPAM, he was admitted with lethargy, vomiting, dehydration, hypotension, and drowsiness. Laboratory results during this hospitalization were as follows: glucose, 2.42 mmol/L (44 mg/dl); sodium, 132 mmol/L; potassuim 3.8 mmol/L; chloride, 101 mmol/L; bicarbonate, 13 mmol/L; BUN, 7.5 mmol/L (21 mg/dL); Cr, 17.68 umol/L (0.2 mg/dL); calcuim, 2.17 mmol/L (8.7 mg/dL); magnesium, 0.57 mmol/L (1.4 mg/dL); and phosphorous, 1.2 mmol/L (3.7 mg/dL).\nAfter the initial resuscitation with boluses of 25% dextrose and normal saline solutions, a repeat glucose test showed a value of 21.78 mmol/L (396 mg/dL). One hour after that, his glucose level dropped again to 2.1 mmol/L (39 mg/dl), and a second 25% dextrose solution bolus was thus given. Our patient had low serum cortisol level, normal aldosterone, and normal growth hormone concentrations . His serum adrenocorticotropic hormone (ACTH) concentration was elevated at 2,630 pg/ml. ACTH stimulation test did not result in an increase in his cortisol levels . He had no detectable anti-adrenal antibodies and a non-reactive purified protein derivative skin test. He was started on hydrocortisone and fludrocortisone and had a surgical removal of the CPAM a few weeks later.\nOur patient's serum ACTH concentration decreased to 13 pg/ml six months after the treatment. A pathological examination of the lung cysts showed multiple thin-walled cysts that ranged from 0.3 cm to 1.5 cm in diameter and filled with clear fluid. The cysts appeared to occupy approximately 90% of our patient's parenchyma. Microscopically, the cysts were lined with columnar (respiratory type) epithelium. This was compatible with the diagnosis of CPAM.\nOne year later, he was readmitted with a seizure and loss of consciousness. A brain magnetic resonance imaging (MRI) revealed bilaterally diffuse symmetric high T2 and FLAIR signal abnormality involving the white matter of several parts of his brain, which was suggestive of a diffuse and active demyelination process . He had elevated VLCFA levels, which was compatible with the diagnosis of X-ALD. His VLCFA levels were as follows: C22:0 of 20.02, C24:0 of 33.61, C26:0 of 1.2, C24 and C22 of 1.679, and C26/C22 of 0.06. Consequently, he was started on anti-seizure medications N-acetyl-L-cysteine, and was continued on corticosteroids. He was also referred for bone marrow transplant evaluation.", + "fulltext_subclaims": [ + "A 3-year-old Arabic boy from Yemen presented with intermittent episodes of shortness of breath, lethargy, fatigability, vomiting, and 'cyanotic' discoloration of his skin, lips, mucous membranes and nail beds for the past two years.", + "He was thought to have methemoglobinemia due to persistent cyanosis.", + "He was born in Yemen and moved to the USA for further treatment one year prior to his visit to our clinic.", + "He had one maternal uncle who died suddenly at 35 years of age.", + "He had 4 full siblings (all males) who died of unknown causes between 2 and 4 years of age.", + "His deceased siblings had similar symptoms and discoloration of mucous membranes.", + "He had 4 other siblings (2 brothers and 2 sisters) who were alive with no medical problems.", + "He had normal electrolytes, blood urea nitrogen (BUN) and creatinine (Cr) levels on several occasions.", + "He had normal results for cardiac examination, echocardiogram, hematologic evaluation and hemoglobin electrophoresis.", + "He was referred to our center for further evaluation of his cyanosis.", + "His arterial blood showed mild hypoxemia as follows: pH 7.32, PaCO2 37.1 mmHg, PaO2 86 mmHg, and HCO3 18.9.", + "His methemoglobin and carboxyhemoglobin levels were 1.10% and 0.3%, respectively.", + "Upon further examination of the film at our clinic, we identified a subtle parenchymal hyperlucency of a large part of his right mid-lung area.", + "His chest computed tomography (CT) scan showed multiple cystic lesions in his right lung that was compatible with CPAM.", + "CT scan of the abdomen showed no abnormalities of the adrenal glands, or other abdominal organs.", + "Before the surgical removal of his CPAM, he was admitted with lethargy, vomiting, dehydration, hypotension, and drowsiness.", + "Laboratory results during this hospitalization were as follows: glucose, 2.42 mmol/L (44 mg/dl); sodium, 132 mmol/L; potassium 3.8 mmol/L; chloride, 101 mmol/L; bicarbonate, 13 mmol/L; BUN, 7.5 mmol/L (21 mg/dL); Cr, 17.68 umol/L (0.2 mg/dL); calcium, 2.17 mmol/L (8.7 mg/dL); magnesium, 0.57 mmol/L (1.4 mg/dL); and phosphorous, 1.2 mmol/L (3.7 mg/dL).", + "After the initial resuscitation with boluses of 25% dextrose and normal saline solutions, a repeat glucose test showed a value of 21.78 mmol/L (396 mg/dL).", + "One hour after that, his glucose level dropped again to 2.1 mmol/L (39 mg/dl), and a second 25% dextrose solution bolus was thus given.", + "Our patient had low serum cortisol level, normal aldosterone, and normal growth hormone concentrations.", + "His serum adrenocorticotropic hormone (ACTH) concentration was elevated at 2,630 pg/ml.", + "ACTH stimulation test did not result in an increase in his cortisol levels.", + "He had no detectable anti-adrenal antibodies and a non-reactive purified protein derivative skin test.", + "He was started on hydrocortisone and fludrocortisone and had a surgical removal of the CPAM a few weeks later.", + "Our patient's serum ACTH concentration decreased to 13 pg/ml six months after the treatment.", + "A pathological examination of the lung cysts showed multiple thin-walled cysts that ranged from 0.3 cm to 1.5 cm in diameter and filled with clear fluid.", + "The cysts appeared to occupy approximately 90% of our patient's parenchyma.", + "Microscopically, the cysts were lined with columnar (respiratory type) epithelium.", + "This was compatible with the diagnosis of CPAM.", + "One year later, he was readmitted with a seizure and loss of consciousness.", + "A brain magnetic resonance imaging (MRI) revealed bilaterally diffuse symmetric high T2 and FLAIR signal abnormality involving the white matter of several parts of his brain, which was suggestive of a diffuse and active demyelination process.", + "He had elevated VLCFA levels, which was compatible with the diagnosis of X-ALD.", + "His VLCFA levels were as follows: C22:0 of 20.02, C24:0 of 33.61, C26:0 of 1.2, C24 and C22 of 1.679, and C26/C22 of 0.06.", + "Consequently, he was started on anti-seizure medications N-acetyl-L-cysteine, and was continued on corticosteroids.", + "He was also referred for bone marrow transplant evaluation." + ], + "summary": "A 3-year-old Arabic boy from Yemen presented with discoloration of the mucous membranes and nail beds, which were considered cyanoses due to methemoglobinemia. He also had shortness of breath, fatigue, emesis and dehydration episodes for which he was admitted to our hospital. Chest radiograph and chest computed tomography scans showed congenital pulmonary adenomatoid malformation. A few weeks before the removal of the malformation, he had a significant episode of hypotension and hypoglycemia. This development required further in-hospital evaluation that led to the diagnosis of adrenal insufficiency and the initiation of treatment with corticosteroids. One year later, he developed seizures and loss of consciousness. Magnetic resonance imaging of his head showed diffuse demyelination secondary to X-linked adrenoleukodystrophy. He was treated with anti-seizure and anti-oxidants, and was referred for bone marrow transplant evaluation.", + "summary_subclaims": [ + "A 3-year-old Arabic boy from Yemen presented with discoloration of the mucous membranes and nail beds.", + "The discoloration was considered cyanoses due to methemoglobinemia.", + "He had shortness of breath.", + "He had fatigue.", + "He had emesis.", + "He had dehydration episodes.", + "Chest radiograph and chest computed tomography scans showed congenital pulmonary adenomatoid malformation.", + "A few weeks before the removal of the malformation, he had a significant episode of hypotension and hypoglycemia.", + "This development required further in-hospital evaluation.", + "The evaluation led to the diagnosis of adrenal insufficiency.", + "Treatment with corticosteroids was initiated.", + "One year later, he developed seizures and loss of consciousness.", + "Magnetic resonance imaging of his head showed diffuse demyelination secondary to X-linked adrenoleukodystrophy.", + "He was treated with anti-seizure and anti-oxidants.", + "He was referred for bone marrow transplant evaluation." + ] + }, + { + "id": "multiclinsum_test_1136_en.txt", + "fulltext": "A 49-year-old man was admitted to Jiangxi Provincial People’s Hospital (the First Affiliated Hospital of Nanchang Medical College, Nanchang, China) with a mass in his right buttock for 4 mo.\nThere was nothing significant about the patient’s present medical history.\nThe patient had a history of sacrococcygeal trauma 3 years before admission, and there were no other abnormalities.\nIn terms of personal and family history, there was nothing of note.\nThere was no abnormality except the fullness in the right rectal wall found during the special anal examination.\nNo obvious abnormality was found in the serum tumor markers.\nMagnetic resonance imaging (MRI) showed a large, well-defined mass located slightly to the right in the center of the pelvic cavity between the left and right obturator muscles . The mass appeared predominantly positioned in the area deep to the gluteus maximus, posterior to the pubic symphysis, underneath the bladder, and above the urogenital septum . It displaced the prostate and seminal vesicle glands to the upper left and pushed the rectum and anal canal close to the left pelvic wall . The mass displayed predominantly isointense T1 signal, which was related to the surrounding musculature and heterogeneous on fat-suppressed T1 (T1FS; Figures , , and ) and T2 (T2FS; Figure ) imaging. There was intralesional focal necrosis and perilesional edema .\nThe mass was surgically excised. During surgery, it was found to be well-circumscribed and with an incomplete capsule and poor mobility, giving a clinical impression of a malignant tumor. Its upper margin reached the seminal-vesicle gland, and the outer edge closely adhered to the right part of the external rectal sphincter, levator ani, and puborectal muscles, but no nerve, vessel, or inguinal lymph node invasion was found.\nOn gross examination, the mass was 13 cm × 12 cm × 8 cm in size, and covered by an incomplete capsule and the remnants of adipose tissue . The cut surface showed a solid, firm-to-elastic, and yellow-pink appearance, with focal cystic degeneration and necrosis within the mass . Histologically, the tumor had a definite capsule ; it was composed of short spindle- to oval-shaped cells and admixed with varying thick bundles of collagen and variable numbers of adipocytes . The cells had eosinophilic cytoplasm with indistinct cell borders and had elongated nuclei with fine chromatin . Hyaline and mucoid degeneration were visible within the tumor. Atypic and bizarre cells could be seen in some areas . It is worth noting that mitotic figures , even atypical mitosis , and multiple necrotic foci and nuclear debris could be seen in the tumor. In addition, smooth muscle and skeletal muscle were invaded within and at the edge of the tumor. These morphological features are often reminiscent of malignant tumors and therefore pose a severe diagnostic challenge to pathologists.\nIHC staining showed that these neoplastic cells were strongly positive for both CD34 and Des , and had lost expression of Rb1 protein . In addition, they showed positive expression of estrogen receptor, epithelial-membrane antigen, human homolog of murine double minute 2 (MDM2), and cyclin-dependent kinase 4 (CDK4) . However, they were negative for S100, smooth muscle actin (SMA), signal transducer and activator of transcription 6 (STAT6), and CD117 . The proliferation index of these neoplastic cells was about 5%, as shown by Ki-67 IHC staining . Fluorescence in situ hybridization (FISH) confirmed the monoallelic and biallelic deletion of the Rb1 and no amplification of MDM2 in these neoplastic cells.\nThe preoperative clinical diagnosis was malignant mesenchymal tumor of the pelvic cavity.", + "fulltext_subclaims": [ + "The patient was a 49-year-old man.", + "He was admitted to Jiangxi Provincial People’s Hospital.", + "He had a mass in his right buttock for 4 mo.", + "There was nothing significant about the patient’s present medical history.", + "The patient had a history of sacrococcygeal trauma 3 years before admission.", + "There were no other abnormalities.", + "In terms of personal and family history, there was nothing of note.", + "There was no abnormality except the fullness in the right rectal wall found during the special anal examination.", + "No obvious abnormality was found in the serum tumor markers.", + "MRI showed a large, well-defined mass located slightly to the right in the center of the pelvic cavity between the left and right obturator muscles.", + "The mass appeared predominantly positioned in the area deep to the gluteus maximus.", + "It was posterior to the pubic symphysis.", + "It was underneath the bladder.", + "It was above the urogenital septum.", + "It displaced the prostate and seminal vesicle glands to the upper left.", + "It pushed the rectum and anal canal close to the left pelvic wall.", + "The mass displayed predominantly isointense T1 signal.", + "It was related to the surrounding musculature.", + "It was heterogeneous on fat-suppressed T1 imaging.", + "It was heterogeneous on fat-suppressed T2 imaging.", + "There was intralesional focal necrosis.", + "There was perilesional edema.", + "The mass was surgically excised.", + "During surgery, it was found to be well-circumscribed.", + "It had an incomplete capsule.", + "It had poor mobility.", + "The upper margin reached the seminal-vesicle gland.", + "The outer edge closely adhered to the right part of the external rectal sphincter.", + "The outer edge closely adhered to the levator ani.", + "The outer edge closely adhered to the puborectal muscles.", + "No nerve invasion was found.", + "No vessel invasion was found.", + "No inguinal lymph node invasion was found.", + "On gross examination, the mass was 13 cm × 12 cm × 8 cm in size.", + "It was covered by an incomplete capsule.", + "It was covered by the remnants of adipose tissue.", + "The cut surface showed a solid, firm-to-elastic, and yellow-pink appearance.", + "There was focal cystic degeneration within the mass.", + "There was necrosis within the mass.", + "The tumor had a definite capsule.", + "It was composed of short spindle- to oval-shaped cells.", + "It was admixed with varying thick bundles of collagen.", + "It was admixed with variable numbers of adipocytes.", + "The cells had eosinophilic cytoplasm.", + "The cells had indistinct cell borders.", + "The cells had elongated nuclei with fine chromatin.", + "Hyaline degeneration was visible within the tumor.", + "Mucoid degeneration was visible within the tumor.", + "Atypic and bizarre cells could be seen in some areas.", + "Mitotic figures could be seen in the tumor.", + "Atypical mitosis could be seen in the tumor.", + "Multiple necrotic foci could be seen in the tumor.", + "Nuclear debris could be seen in the tumor.", + "Smooth muscle was invaded within and at the edge of the tumor.", + "Skeletal muscle was invaded within and at the edge of the tumor.", + "These morphological features are often reminiscent of malignant tumors.", + "These morphological features pose a severe diagnostic challenge to pathologists.", + "IHC staining showed that these neoplastic cells were strongly positive for CD34.", + "IHC staining showed that these neoplastic cells were strongly positive for Des.", + "IHC staining showed that these neoplastic cells had lost expression of Rb1 protein.", + "IHC staining showed that these neoplastic cells were positive for estrogen receptor.", + "IHC staining showed that these neoplastic cells were positive for epithelial-membrane antigen.", + "IHC staining showed that these neoplastic cells were positive for MDM2.", + "IHC staining showed that these neoplastic cells were positive for CDK4.", + "IHC staining showed that these neoplastic cells were negative for S100.", + "IHC staining showed that these neoplastic cells were negative for SMA.", + "IHC staining showed that these neoplastic cells were negative for STAT6.", + "IHC staining showed that these neoplastic cells were negative for CD117.", + "The proliferation index of these neoplastic cells was about 5%.", + "FISH confirmed the monoallelic and biallelic deletion of the Rb1.", + "FISH confirmed no amplification of MDM2.", + "The preoperative clinical diagnosis was malignant mesenchymal tumor of the pelvic cavity." + ], + "summary": "A 49-year-old man complained of pain and discomfort in the right buttock for more than 4 mo and did not receive any treatment. Nuclear magnetic resonance imaging (MRI) showed a 13-cm-sized mass in his right pelvic cavity. Histologically significant differences were atypical mitosis figures and multiple necrotic foci in the tumor. In addition, smooth muscle and skeletal muscle were invaded within and at the edge of the tumor. These morphologic features are often reminiscent of malignant tumors and therefore pose a diagnostic challenge to pathologists. The tumor cells were strongly positive for both cluster of differentiation 34 and desmin, and the loss of retinoblastoma 1 shown by immunohistochemical and fluorescence in situ hybridization results confirmed the pathological diagnosis of MTMF. Currently, the patient is alive and in good condition without tumor recurrence or metastasis after 2.5 years of follow-up by telephone and MRI.", + "summary_subclaims": [ + "The patient is a 49-year-old man.", + "He complained of pain and discomfort in the right buttock for more than 4 mo.", + "He did not receive any treatment.", + "Nuclear magnetic resonance imaging showed a 13-cm-sized mass in his right pelvic cavity.", + "Histologically significant differences were atypical mitosis figures.", + "Multiple necrotic foci were present in the tumor.", + "Smooth muscle and skeletal muscle were invaded within and at the edge of the tumor.", + "The tumor cells were strongly positive for cluster of differentiation 34.", + "The tumor cells were strongly positive for desmin.", + "The loss of retinoblastoma 1 was shown by immunohistochemical and fluorescence in situ hybridization results.", + "The pathological diagnosis was MTMF.", + "The patient is alive and in good condition.", + "There has been no tumor recurrence or metastasis after 2.5 years of follow-up." + ] + }, + { + "id": "multiclinsum_test_2404_en.txt", + "fulltext": "A 78-year-old Japanese man underwent a bilateral partial nephrectomy for bilateral RCC 8 years ago. The pathological diagnosis was ccRCC. Seven years after bilateral partial nephrectomy, solitary lung metastasis appeared at the hilar region in the right lower lobe of the lung; thus, he underwent a thoracoscopic resection of the lobe, and it was pathologically diagnosed as metastatic ccRCC. Eight years after bilateral partial nephrectomy, multiple metastases to the pancreas and liver occurred. Biopsy revealed pancreatic and liver metastases from ccRCC. He started systemic therapy with ipilimumab (1 mg/kg) and nivolumab (240 mg). After 4 cycles (1 cycle/3 weeks) of combination therapy, nivolumab (240 mg) was continued every 2 weeks. Three months after initiating ICI therapy, he developed type 1 diabetes mellitus, and insulin replacement therapy was initiated. He also subsequently developed panhypopituitarism, necessitating hydrocortisone replacement therapy (15 mg daily). Fifteen months after initiation of ICI, he experienced right knee joint pain, and 22 months later, indurated swelling with edema in both limb joints also materialized . Laboratory tests indicated elevated inflammatory markers with C-reactive protein of 9.00 mg/dL, erythrocyte sedimentation rate of 86 mm, and matrix metalloproteinase-3 of 999.2 ng/mL. However, RF and anti-CCP antibodies were negative, as were other autoantibodies. Ultrasonography revealed synovitis and hypervascularity in the symptomatic joints. X-ray findings of the hands and legs presented osteophyte formations and bone erosions in 11 areas. This case was diagnosed as seronegative rheumatoid arthritis according to the ACR/EULAR rheumatoid arthritis classification criteria with a total score of 7 and negative RF and anti-CCP antibodies. He had no past or family history of connective tissue disease or inflammatory arthritis. Nivolumab was suspended, and PSL treatment was initiated at 20 mg daily. Two days post-treatment, limb swelling improved, and the pain vanished after 7 days . Inflammatory markers returned to normal. PSL was gradually tapered to 9 mg/day 7 weeks after initiation, and nivolumab 240 mg was restarted. The metastatic lesions in the pancreas and liver did not increase in size during cessation of nivolumab . He remained stable after the resumption of ICI without recurrence of arthralgia or other irAEs.", + "fulltext_subclaims": [ + "The patient is a 78-year-old Japanese man.", + "He underwent a bilateral partial nephrectomy for bilateral RCC 8 years ago.", + "The pathological diagnosis was clear cell renal cell carcinoma (ccRCC).", + "Seven years after bilateral partial nephrectomy, solitary lung metastasis appeared at the hilar region in the right lower lobe of the lung.", + "He underwent a thoracoscopic resection of the lobe.", + "The thoracoscopic resection was pathologically diagnosed as metastatic ccRCC.", + "Eight years after bilateral partial nephrectomy, multiple metastases to the pancreas and liver occurred.", + "Biopsy revealed pancreatic and liver metastases from ccRCC.", + "He started systemic therapy with ipilimumab (1 mg/kg) and nivolumab (240 mg).", + "After 4 cycles of combination therapy, nivolumab (240 mg) was continued every 2 weeks.", + "Three months after initiating immune checkpoint inhibitor (ICI) therapy, he developed type 1 diabetes mellitus.", + "Insulin replacement therapy was initiated.", + "He also subsequently developed panhypopituitarism.", + "Hydrocortisone replacement therapy (15 mg daily) was initiated.", + "Fifteen months after initiation of ICI, he experienced right knee joint pain.", + "Twenty-two months after initiation of ICI, indurated swelling with edema in both limb joints materialized.", + "Laboratory tests indicated elevated inflammatory markers with C-reactive protein of 9.00 mg/dL.", + "Erythrocyte sedimentation rate was 86 mm.", + "Matrix metalloproteinase-3 was 999.2 ng/mL.", + "Rheumatoid factor and anti-CCP antibodies were negative.", + "Other autoantibodies were negative.", + "Ultrasonography revealed synovitis and hypervascularity in the symptomatic joints.", + "X-ray findings of the hands and legs presented osteophyte formations and bone erosions in 11 areas.", + "This case was diagnosed as seronegative rheumatoid arthritis according to the ACR/EULAR rheumatoid arthritis classification criteria with a total score of 7.", + "Nivolumab was suspended.", + "Prednisolone (PSL) treatment was initiated at 20 mg daily.", + "Two days post-treatment, limb swelling improved.", + "The pain vanished after 7 days.", + "Inflammatory markers returned to normal.", + "PSL was gradually tapered to 9 mg/day 7 weeks after initiation.", + "Nivolumab 240 mg was restarted.", + "The metastatic lesions in the pancreas and liver did not increase in size during cessation of nivolumab.", + "He remained stable after the resumption of ICI without recurrence of arthralgia or other immune-related adverse events." + ], + "summary": "A 78-year-old Japanese man with renal cell carcinoma developed pancreatic and liver metastases after bilateral partial nephrectomy and was treated with ipilimumab and nivolumab. After 22 months, he developed arthralgia in limbs and knee joints, accompanied by limb swelling. The diagnosis was seronegative rheumatoid arthritis. Nivolumab was discontinued, and prednisolone was initiated, quickly improving symptoms. Although nivolumab was resumed after 2 months, arthritis did not recur.", + "summary_subclaims": [ + "The patient is a 78-year-old Japanese man.", + "The patient had renal cell carcinoma.", + "The patient developed pancreatic and liver metastases.", + "The patient was treated with ipilimumab and nivolumab.", + "After 22 months, the patient developed arthralgia in limbs and knee joints.", + "The arthralgia was accompanied by limb swelling.", + "The diagnosis was seronegative rheumatoid arthritis.", + "Nivolumab was discontinued.", + "Prednisolone was initiated.", + "Symptoms improved quickly after prednisolone was initiated.", + "Nivolumab was resumed after 2 months.", + "Arthritis did not recur after nivolumab was resumed." + ] + }, + { + "id": "multiclinsum_test_2832_en.txt", + "fulltext": "A 26-year-old Colombian male without past medical history presented to the emergency department with a 1-month history of dry cough, progressive dyspnoea, and orthopnoea. On physical examination, his blood pressure was normal (110/70 mmHg), but he exhibited tachycardia (110 b.p.m.), and elevated jugular venous pressure. No cardiac murmurs or lung rales were detected. The electrocardiogram revealed generalized low voltages, and blood test results were unremarkable. A chest X-ray showed significantly enlarged cardiac silhouette . A subsequent computed tomography (CT) scan confirmed the presence of a giant aneurysm in the ascending thoracic aorta (maximum diameter 96 mm) and a massive pericardial effusion (maximum diameter 65 mm). The remaining aorta and its branches appeared to be of normal calibre. A bedside echocardiogram indicated signs of cardiac tamponade and, because of rapid worsening symptoms, emergent pericardiocentesis was performed to stabilize the patient. The obtained pericardial fluid was serosanguinous. Subsequently, the patient was admitted to the intensive care unit for further stabilization.\nA transoesophageal echocardiogram revealed severe aortic regurgitation , with a broad and dense central jet resulting from a large coaptation defect secondary to the enlarged ascending aorta. Holodiastolic flow reversal in the descending aorta was observed, with an end-diastolic velocity of 40 cm/s. The estimated effective regurgitant orifice area was 1.5 cm2. Left ventricular diameters and function were normal, suggesting an acute/sub-acute onset. The overall clinical presentation strongly indicated an impending aortic rupture. On 4th day, the patient underwent ascending aorta replacement with a Bentall´s procedure using a 25 mm CarbosealTM mechanical prosthesis and a 28 mm Dacron aortic graft. The excised tissue was sent for pathological analysis, which revealed a thin aortic wall and histological evidence of medial degeneration and disorganization of elastic fibres . There were not intra- nor post-operative complications, and the patient was discharged from the hospital after 1 week.\nFollowing discharge, the patient was assessed by the Inherited Cardiovascular Diseases Unit. While there was no significant family history, physical examination unveiled dolichocephaly with mild retrognathia, arachnodactyly, joint laxity, and a high-arched palate. The Gante’s systemic score was 4. A genetic study using next generation sequencing (NGS) encompassing 64 genes related to aortic and connective tissue disorders was conducted. The genetic variant c.409A > T, p.Ser137Cys, in EFEMP2 was identified in homozygous state. Cascade screening of first-degree relatives revealed that they were healthy heterozygous carriers.\nSubsequent CT scan of the entire vascular system 1 year after surgery did not reveal aneurysms in other locations, although arterial tortuosity was noticed. After 2 years of follow-up, the patient has been managed with losartan 50 mg and acenocoumarol, with no further reported events.", + "fulltext_subclaims": [ + "The patient is a 26-year-old Colombian male.", + "The patient had no past medical history.", + "The patient presented with a 1-month history of dry cough.", + "The patient had progressive dyspnoea.", + "The patient had orthopnoea.", + "On physical examination, blood pressure was normal (110/70 mmHg).", + "The patient exhibited tachycardia (110 b.p.m.).", + "Elevated jugular venous pressure was noted.", + "No cardiac murmurs were detected.", + "No lung rales were detected.", + "The electrocardiogram revealed generalized low voltages.", + "Blood test results were unremarkable.", + "A chest X-ray showed significantly enlarged cardiac silhouette.", + "A CT scan confirmed the presence of a giant aneurysm in the ascending thoracic aorta.", + "The maximum diameter of the aneurysm was 96 mm.", + "A massive pericardial effusion was present.", + "The maximum diameter of the pericardial effusion was 65 mm.", + "The remaining aorta and its branches appeared to be of normal calibre.", + "A bedside echocardiogram indicated signs of cardiac tamponade.", + "Emergent pericardiocentesis was performed.", + "The obtained pericardial fluid was serosanguinous.", + "The patient was admitted to the intensive care unit.", + "A transoesophageal echocardiogram revealed severe aortic regurgitation.", + "The aortic regurgitation was due to a large coaptation defect.", + "The coaptation defect was secondary to the enlarged ascending aorta.", + "Holodiastolic flow reversal in the descending aorta was observed.", + "The end-diastolic velocity was 40 cm/s.", + "The estimated effective regurgitant orifice area was 1.5 cm2.", + "Left ventricular diameters and function were normal.", + "The clinical presentation strongly indicated an impending aortic rupture.", + "The patient underwent ascending aorta replacement with a Bentall’s procedure.", + "The procedure used a 25 mm CarbosealTM mechanical prosthesis.", + "The procedure used a 28 mm Dacron aortic graft.", + "The excised tissue showed a thin aortic wall.", + "Histological evidence of medial degeneration was found.", + "Disorganization of elastic fibres was noted.", + "There were no intra- or post-operative complications.", + "The patient was discharged after 1 week.", + "The patient was assessed by the Inherited Cardiovascular Diseases Unit.", + "Physical examination revealed dolichocephaly with mild retrognathia.", + "Arachnodactyly was noted.", + "Joint laxity was noted.", + "A high-arched palate was noted.", + "The Gante’s systemic score was 4.", + "A genetic study using NGS encompassing 64 genes was conducted.", + "The genetic variant c.409A > T, p.Ser137Cys, in EFEMP2 was identified.", + "The variant was in homozygous state.", + "Cascade screening of first-degree relatives revealed they were healthy heterozygous carriers.", + "A subsequent CT scan of the entire vascular system was performed 1 year after surgery.", + "No aneurysms were found in other locations.", + "Arterial tortuosity was noticed.", + "After 2 years of follow-up, the patient was managed with losartan 50 mg.", + "After 2 years of follow-up, the patient was managed with acenocoumarol.", + "No further reported events occurred." + ], + "summary": "We present the case of a 26-year-old male with a giant ascending aorta aneurysm and massive pericardial effusion, which was ultimately diagnosed of CL1B due to the p.Ser137Cys variant in the EFEMP2 gene in homozygosis. The patient underwent successful ascending aorta replacement (Bentall´s procedure). There were not complications or further events after 2 years of follow-up.", + "summary_subclaims": [ + "The patient is a 26-year-old male.", + "The patient had a giant ascending aorta aneurysm.", + "The patient had a massive pericardial effusion.", + "The patient was ultimately diagnosed of CL1B.", + "The diagnosis was due to the p.Ser137Cys variant in the EFEMP2 gene.", + "The variant was in homozygosis.", + "The patient underwent ascending aorta replacement.", + "The procedure was a Bentall´s procedure.", + "There were not complications after the procedure.", + "There were not further events after 2 years of follow-up." + ] + }, + { + "id": "multiclinsum_test_252_en.txt", + "fulltext": "A morbidly obese 32-year-old Asian female with a body mass index of 52 and a history of meningioma excision and asthma, presented to the emergency room (ER) with a positive COVID-19 test and shortness of breath, cough, and diarrhea. She was hypoxic with oxygen saturation via pulse oximetry (SpO2) of 88% on room air, tachypneic with respiratory rate of 35, febrile with temperature of 100.5 F, pulse rate 89, and blood pressure 106/84. CXR demonstrated bilateral basal multifocal infiltrates. She was admitted on 5 L/min of O2. The patient experienced symptoms 7 days prior to presenting to the ER. Upon admission, the patient was confirmed to be SARS-CoV-2 positive by nasopharyngeal swab and reverse transcription-polymerase chain reaction with an Abbott ID system. The patient was started on Ceftriaxone and Azithromycin for potential superimposed bacterial infection. She was considered high risk due to morbid obesity, asthma, low oxygen saturation, infiltrates on CXR, and tachypnea. Her condition worsened despite antibiotics and supportive therapy and was evaluated for ICU admission on hospital day 3. Consent was obtained for the institutional review board (IRB)-approved randomized clinical trial of LLLT for COVID-19. LLLT treatment started on hospital day 3 while antibiotics continued. The patient was not receiving any antiviral or steroid medications.\nThe patient’s response to LLLT was evaluated via SMART-COP (systolic blood pressure, multilobar infiltrates, albumin, respiratory rate, tachycardia, confusion, oxygen, and pH) and Brescia-COVID prediction tools, CXR radiographic assessment of lung edema (RALE) , and blood markers of inflammation .\nThe SMART-COP Score evaluates pneumonia severity and predicts the need for intensive respiratory or vasopressor support (IRVS) in community-acquired pneumonia. The pretreatment SMART-COP score was 5, indicating potential serious progressive complications, rapid referral to the ICU, and the need for a ventilator. The Brescia-COVID Respiratory Severity Scale is a stepwise algorithm for managing patients with confirmed COVID-19. Pretreatment score was 4, which predicted ICU and ventilator support.\nThe RALE score [, ] evaluates lung edema by CXR in ARDS patients. To quantify the extent of infection, a severity score was calculated by adapting and simplifying RALE score . A score of 0–4 was assigned to each lung depending on the extent of involvement by consolidation or ground glass opacities (0 = no involvement; 1 = <25%; 2 = 25%–50%; 3 = 50%–75%; 4 = >75% involvement). The scores for each lung were summed up to produce the final severity score . Before treatment, the RALE score was 8, consistent with 100% involvement of the lungs.\nPrior to LLLT, the patient had significant tachypnea and complained of “terrible shortness of breath” with activities of daily living.\nThe multiwave locked system (MLS) scanner-equipped laser utilized in this study was deemed a nonsignificant risk device by the US Food and Drug Administration (FDA) prior to obtaining IRB approval. An FDA-cleared laser system (MLS-ASA/Italy) typically used in pain clinics was employed. Two simultaneous and synchronized laser diodes, emitting at 905 and 808 nm, were used in pulsed modes . The scanner was positioned 20 cm above the skin, according to the manufacturer specifications. Each lung was scanned for 14 min, from apex to base over 250 cm2 of the posterior thorax, . The patient tolerated all four consecutive once-daily LLLT without complication.\nDuring the first laser treatment, her SpO2 increased from 92% to 97% on 3 L/min oxygen within 10 min of starting treatment. After the second laser treatment the patient was breathing without dyspnea. Following treatments her respiratory rate returned to normal 19–20 breaths/min. After the fourth treatment, the patient was able to independently ambulate and had improved ability to perform activities of daily living. Patient was discharged 2 days after her last treatment on 1 L/min oxygen. Total hospital stay was 7 days. On follow-up 2 days after discharge, she was weaned to room air. The SMART-COP score decreased from 4 to 1 after treatment, indicating low risk for IRVS and requiring observation only. The Brescia-COVID score decreased from 4 to 0 after treatment, which supports patient monitoring via pulse oximetry and clinical evaluation.\nBefore treatment, the RALE score was 8, consistent with 100% involvement of the lungs, and it diminished to three after LLLT. The imaging absorption stage for severe COVID-19 is typically seen after ≥14 days , but in this case, the absorption stage is evident at 7 days .\nBlood work included pre- and post-LLLT, IL-6, ferritin, and CRP. Immediately after final treatment IL-6 dropped from 45.89 to 11.7 pg/mL, ferritin from 359 to 175 ng/mL, and CRP improved from 3.06 to 1.43 mg/dL .\nOxygen requirement before treatment was 3–6 L/min with SpO2 88%–93% and improved to 1–3 L/min and SpO2 97%–99% after treatment.\nAt 2 weeks and 6 weeks from discharge the patient reported subjective improvement in respiratory symptoms and well-being. She was satisfied and appreciative of her LLLT experience and treatment outcome.", + "fulltext_subclaims": [ + "The patient was a 32-year-old Asian female.", + "She had a body mass index of 52.", + "She had a history of meningioma excision.", + "She had a history of asthma.", + "She presented with a positive COVID-19 test.", + "She had shortness of breath.", + "She had a cough.", + "She had diarrhea.", + "Her oxygen saturation via pulse oximetry was 88% on room air.", + "Her respiratory rate was 35.", + "Her temperature was 100.5 F.", + "Her pulse rate was 89.", + "Her blood pressure was 106/84.", + "Chest X-ray demonstrated bilateral basal multifocal infiltrates.", + "She was admitted on 5 L/min of O2.", + "She was confirmed to be SARS-CoV-2 positive by nasopharyngeal swab and reverse transcription-polymerase chain reaction with an Abbott ID system.", + "She was started on Ceftriaxone and Azithromycin.", + "She was considered high risk due to morbid obesity.", + "She was considered high risk due to asthma.", + "She was considered high risk due to low oxygen saturation.", + "She was considered high risk due to infiltrates on CXR.", + "She was considered high risk due to tachypnea.", + "Her condition worsened despite antibiotics and supportive therapy.", + "She was evaluated for ICU admission on hospital day 3.", + "Consent was obtained for the IRB-approved randomized clinical trial of LLLT for COVID-19.", + "LLLT treatment started on hospital day 3.", + "The patient was not receiving any antiviral or steroid medications.", + "The SMART-COP score evaluates pneumonia severity and predicts the need for intensive respiratory or vasopressor support.", + "The pretreatment SMART-COP score was 5.", + "The pretreatment SMART-COP score indicated potential serious progressive complications.", + "The pretreatment SMART-COP score indicated the need for rapid referral to the ICU.", + "The pretreatment SMART-COP score indicated the need for a ventilator.", + "The Brescia-COVID Respiratory Severity Scale is a stepwise algorithm for managing patients with confirmed COVID-19.", + "The pretreatment Brescia-COVID score was 4.", + "The pretreatment Brescia-COVID score predicted ICU and ventilator support.", + "The RALE score evaluates lung edema by CXR in ARDS patients.", + "A severity score was calculated by adapting and simplifying the RALE score.", + "A score of 0–4 was assigned to each lung depending on the extent of involvement by consolidation or ground glass opacities.", + "The scores for each lung were summed up to produce the final severity score.", + "The pretreatment RALE score was 8.", + "The pretreatment RALE score was consistent with 100% involvement of the lungs.", + "The patient had significant tachypnea.", + "The patient complained of 'terrible shortness of breath' with activities of daily living.", + "The MLS scanner-equipped laser was deemed a nonsignificant risk device by the FDA.", + "An FDA-cleared laser system (MLS-ASA/Italy) was employed.", + "Two simultaneous and synchronized laser diodes, emitting at 905 and 808 nm, were used in pulsed modes.", + "The scanner was positioned 20 cm above the skin.", + "Each lung was scanned for 14 min.", + "Each lung was scanned from apex to base over 250 cm2 of the posterior thorax.", + "The patient tolerated all four consecutive once-daily LLLT without complication.", + "During the first laser treatment, her SpO2 increased from 92% to 97% on 3 L/min oxygen within 10 min of starting treatment.", + "After the second laser treatment, the patient was breathing without dyspnea.", + "Following treatments, her respiratory rate returned to normal 19–20 breaths/min.", + "After the fourth treatment, the patient was able to independently ambulate.", + "After the fourth treatment, the patient had improved ability to perform activities of daily living.", + "The patient was discharged 2 days after her last treatment.", + "The patient was discharged on 1 L/min oxygen.", + "The total hospital stay was 7 days.", + "On follow-up 2 days after discharge, she was weaned to room air.", + "The SMART-COP score decreased from 4 to 1 after treatment.", + "The SMART-COP score after treatment indicated low risk for IRVS.", + "The SMART-COP score after treatment indicated the need for observation only.", + "The Brescia-COVID score decreased from 4 to 0 after treatment.", + "The Brescia-COVID score after treatment supports patient monitoring via pulse oximetry and clinical evaluation.", + "The RALE score diminished to three after LLLT.", + "The imaging absorption stage for severe COVID-19 is typically seen after ≥14 days.", + "In this case, the absorption stage was evident at 7 days.", + "Blood work included pre- and post-LLLT IL-6, ferritin, and CRP.", + "Immediately after final treatment, IL-6 dropped from 45.89 to 11.7 pg/mL.", + "Immediately after final treatment, ferritin dropped from 359 to 175 ng/mL.", + "Immediately after final treatment, CRP improved from 3.06 to 1.43 mg/dL.", + "Oxygen requirement before treatment was 3–6 L/min with SpO2 88%–93%.", + "Oxygen requirement after treatment improved to 1–3 L/min and SpO2 97%–99%.", + "At 2 weeks and 6 weeks from discharge, the patient reported subjective improvement in respiratory symptoms.", + "At 2 weeks and 6 weeks from discharge, the patient reported subjective improvement in well-being.", + "The patient was satisfied and appreciative of her LLLT experience.", + "The patient was satisfied and appreciative of her treatment outcome." + ], + "summary": "A morbidly obese 32-year-old Asian female with severe COVID-19 received four consecutive once-daily LLLT sessions via a laser scanner. Pulsed 808 nm and 905 nm laser beams were delivered over the posterior chest for 28 min. The patient was evaluated before and after LLLT by radiological assessment of lung edema (RALE) on chest X-ray, oxygen requirements and saturation, pneumonia severity indices (SMART-COP and Brescia-COVID), blood inflammatory markers (interleukin-6, ferritin, and C-Reactive protein (CRP)). Prior to treatment, oxygen saturation (SpO2) via pulse oximetry was 88%-93% on 5-6 L oxygen. Following LLLT, SpO2 increased to 97%-99% on 1-3 L oxygen. Reductions in RALE score from 8 to 3, Brescia-COVID from 4 to 0, and SMART-COP from 5 to 0 were observed. Interleukin-6 decreased from 45.89 to 11.7 pg/mL, ferritin from 359 to 175 ng/mL, and CRP from 3.04 to 1.43 mg/dL. Post-treatment, the patient noted appreciable improvement in respiratory symptoms.", + "summary_subclaims": [ + "The patient was a morbidly obese 32-year-old Asian female.", + "The patient had severe COVID-19.", + "The patient received four consecutive once-daily LLLT sessions.", + "The LLLT was delivered via a laser scanner.", + "Pulsed 808 nm and 905 nm laser beams were used.", + "The laser beams were delivered over the posterior chest.", + "Each LLLT session lasted 28 minutes.", + "The patient was evaluated before and after LLLT.", + "Radiological assessment of lung edema (RALE) was performed on chest X-ray.", + "Oxygen requirements and saturation were measured.", + "Pneumonia severity indices (SMART-COP and Brescia-COVID) were assessed.", + "Blood inflammatory markers (interleukin-6, ferritin, and CRP) were measured.", + "Prior to treatment, oxygen saturation was 88%-93% on 5-6 L oxygen.", + "Following LLLT, oxygen saturation increased to 97%-99% on 1-3 L oxygen.", + "The RALE score decreased from 8 to 3.", + "The Brescia-COVID score decreased from 4 to 0.", + "The SMART-COP score decreased from 5 to 0.", + "Interleukin-6 decreased from 45.89 to 11.7 pg/mL.", + "Ferritin decreased from 359 to 175 ng/mL.", + "CRP decreased from 3.04 to 1.43 mg/dL.", + "The patient noted appreciable improvement in respiratory symptoms." + ] + }, + { + "id": "multiclinsum_test_1994_en.txt", + "fulltext": "A 55-year-old man was hospitalized after he discovered a painless perianal mass.\nThe patient’s symptoms started 10 d prior to presentation.\nThe patient had no relevant previous medical history.\nThe patient’s family history was unremarkable.\nA lump approximately 3 cm × 4 cm could be felt in the 7 to 8 o’clock direction of the perianal area.\nAfter admission to the inpatient ward, laboratory examinations were carried out, which included routine blood tests , routine tests for stool plus occult blood, and tests for liver and kidney function, electrolytes, blood coagulation function, and tumor biomarkers. Preoperative examinations ruled out hepatitis B, hepatitis C, syphilis, and human immunodeficiency virus. All results were within normal ranges.\nPostoperative pathology showed that a lump approximately 8 cm × 6.5 cm × 5 cm with a clear boundary, regional capsule, surface color of gray or taupe, interior color of gray, likely nodules, and mucoid changes in some areas was observed .\nImmunohistochemistry showed that the tumor cells were diffusely and strongly positive for CD34 and vimentin, but negative for CD31, S100, desmin, EMA, SMA, CD117, Dog-1, CK-P, INI1, CD68, CD99, STAT6, β-catenin, HMB45, and ALK (D5F3) . The Ki-67 index was < 1%.\nUltrasound showed a 7.9 cm × 7.6 cm cystic mass in the 1 to 5 o’clock direction in the knee-chest position. The border was clear with poor entrant sound and rear echo enhancement. Many vascular signals could be detected around the mass .", + "fulltext_subclaims": [ + "A 55-year-old man was hospitalized after he discovered a painless perianal mass.", + "The patient’s symptoms started 10 d prior to presentation.", + "The patient had no relevant previous medical history.", + "The patient’s family history was unremarkable.", + "A lump approximately 3 cm × 4 cm could be felt in the 7 to 8 o’clock direction of the perianal area.", + "After admission to the inpatient ward, laboratory examinations were carried out, which included routine blood tests, routine tests for stool plus occult blood, and tests for liver and kidney function, electrolytes, blood coagulation function, and tumor biomarkers.", + "Preoperative examinations ruled out hepatitis B, hepatitis C, syphilis, and human immunodeficiency virus.", + "All results were within normal ranges.", + "Postoperative pathology showed that a lump approximately 8 cm × 6.5 cm × 5 cm with a clear boundary, regional capsule, surface color of gray or taupe, interior color of gray, likely nodules, and mucoid changes in some areas was observed.", + "Immunohistochemistry showed that the tumor cells were diffusely and strongly positive for CD34 and vimentin.", + "The tumor cells were negative for CD31, S100, desmin, EMA, SMA, CD117, Dog-1, CK-P, INI1, CD68, CD99, STAT6, β-catenin, HMB45, and ALK (D5F3).", + "The Ki-67 index was < 1%.", + "Ultrasound showed a 7.9 cm × 7.6 cm cystic mass in the 1 to 5 o’clock direction in the knee-chest position.", + "The border was clear with poor entrant sound and rear echo enhancement.", + "Many vascular signals could be detected around the mass." + ], + "summary": "A 55-year-old man was hospitalized upon discovering a painless perianal lump 10 d prior. Physical examination showed a lump of approximately 3 cm × 4 cm in the 7 to 8 o'clock direction in the perianal area. Perianal abscess was considered the primary diagnosis. Lump removal surgery was performed under epidural anesthesia. Postoperative pathology showed a well-circumscribed, soft tissue-derived, spindle-cell tumor with strong CD34 positivity by immunohistochemistry. The final diagnosis was perianal SCPFT. There were no complications, and the patient was followed for more than 8 mo without recurrence or metastasis.", + "summary_subclaims": [ + "A 55-year-old man was hospitalized upon discovering a painless perianal lump 10 d prior.", + "Physical examination showed a lump of approximately 3 cm × 4 cm in the 7 to 8 o'clock direction in the perianal area.", + "Perianal abscess was considered the primary diagnosis.", + "Lump removal surgery was performed under epidural anesthesia.", + "Postoperative pathology showed a well-circumscribed, soft tissue-derived, spindle-cell tumor.", + "The tumor showed strong CD34 positivity by immunohistochemistry.", + "The final diagnosis was perianal SCPFT.", + "There were no complications.", + "The patient was followed for more than 8 mo without recurrence or metastasis." + ] + }, + { + "id": "multiclinsum_test_2587_en.txt", + "fulltext": "An 81-year-old man presented to the emergency department complaining of epigastric pain and tarry stool passage that lasted for 3 d.\nOf 3 d prior to admission, the patient developed epigastric pain and tarry stool passage. Because of progressive symptoms, he was brought to the emergency department of our hospital.\nPrior to this incident, he was admitted to the hospital three times in 6 mo due to acute cardiopulmonary distress. The first admission was for lung fibrosis exacerbated by pneumonia, pleural effusion, and congestive heart failure, with an ejection fraction of 25%; the second admission occurred 2 mo later for pulmonary edema; and the third admission occurred in the following month as a result of coronary artery disease (CAD) accompanied by cardiogenic shock and acute pulmonary congestion. His CAD was treated using percutaneous transluminal coronary angioplasty with the initiation of antiplatelet therapy.\nNo remarkable history.\nThe patient presented with slight hypotension without tachycardia or fever (blood pressure, 92/60 mmHg; pulse rate, 62 bpm; body temperature, 36.9 °C). The patient appeared mild confused with limited activity due to general weakness. Mild abdominal distension with poor appetite was complained, but no dizziness, shortness of breath, chest tightness, abdominal pain or decreased urine amount was noticed. Further physical examination revealed a soft abdomen without obvious point tenderness, muscle guarding or rebounding pain. He was not pale nor icteric.\nLaboratory tests indicated leukocytosis with left shift (white blood cell count, 10600/μL; segment, 73.3%), direct bilirubinemia (direct bilirubin, 0.7 mg/dL; total bilirubin, 1.6 mg/dL) and elevated liver enzyme levels (alanine aminotransferase, 648 IU/L; aspartate aminotransferase, 130 IU/L); anemia, thrombocytopenia, renal insufficiency, and electrolyte imbalance were not detected. Virology tests also confirmed the absence of hepatitis B or C viral infection.\nThe patient was then admitted to a gastroenterology ward owing to suspicion of cholecystitis and upper gastrointestinal bleeding. Abdominal ultrasound revealed the presence of gallbladder sludge. An abdominal computed tomography (CT) scan with contrast was performed the next afternoon; the scan revealed an enhancing pseudoaneurysm of the cystic artery with high-density material in the gallbladder and common bile duct (CBD) and mild dilatation of the bilateral intrahepatic duct (IHD) and CBD .", + "fulltext_subclaims": [ + "The patient is an 81-year-old man.", + "The patient presented to the emergency department complaining of epigastric pain and tarry stool passage that lasted for 3 d.", + "The patient developed epigastric pain and tarry stool passage 3 d prior to admission.", + "The patient was brought to the emergency department because of progressive symptoms.", + "The patient was admitted to the hospital three times in 6 mo due to acute cardiopulmonary distress.", + "The first admission was for lung fibrosis exacerbated by pneumonia, pleural effusion, and congestive heart failure.", + "The first admission occurred with an ejection fraction of 25%.", + "The second admission occurred 2 mo later for pulmonary edema.", + "The third admission occurred in the following month as a result of coronary artery disease (CAD) accompanied by cardiogenic shock and acute pulmonary congestion.", + "The patient's CAD was treated using percutaneous transluminal coronary angioplasty.", + "The patient's CAD treatment included the initiation of antiplatelet therapy.", + "The patient presented with slight hypotension without tachycardia or fever.", + "The patient's blood pressure was 92/60 mmHg.", + "The patient's pulse rate was 62 bpm.", + "The patient's body temperature was 36.9 °C.", + "The patient appeared mild confused with limited activity due to general weakness.", + "The patient complained of mild abdominal distension with poor appetite.", + "No dizziness, shortness of breath, chest tightness, abdominal pain, or decreased urine amount was noticed.", + "Further physical examination revealed a soft abdomen without obvious point tenderness, muscle guarding, or rebounding pain.", + "The patient was not pale nor icteric.", + "Laboratory tests indicated leukocytosis with left shift.", + "The white blood cell count was 10600/μL.", + "The segment count was 73.3%.", + "Direct bilirubin was 0.7 mg/dL.", + "Total bilirubin was 1.6 mg/dL.", + "Alanine aminotransferase was 648 IU/L.", + "Aspartate aminotransferase was 130 IU/L.", + "Anemia, thrombocytopenia, renal insufficiency, and electrolyte imbalance were not detected.", + "Virology tests confirmed the absence of hepatitis B or C viral infection.", + "The patient was admitted to a gastroenterology ward owing to suspicion of cholecystitis and upper gastrointestinal bleeding.", + "Abdominal ultrasound revealed the presence of gallbladder sludge.", + "An abdominal computed tomography (CT) scan with contrast was performed the next afternoon.", + "The CT scan revealed an enhancing pseudoaneurysm of the cystic artery.", + "The CT scan showed high-density material in the gallbladder and common bile duct (CBD).", + "The CT scan showed mild dilatation of the bilateral intrahepatic duct (IHD) and CBD." + ], + "summary": "An 81-year-old man complained of epigastric pain and tarry stool passage that lasted for 3 d. He had a medical history of poor cardiopulmonary function. The computed tomographic scan of abdomen showed cystic artery pseudoaneurysm and dilatation of gallbladder. Because of high adverse outcomes related to general anesthesia, the patient was successfully managed with endovascular embolization for this cystic artery pseudoaneurysm and percutaneous drainage for the distended gallbladder.", + "summary_subclaims": [ + "The patient is an 81-year-old man.", + "The patient complained of epigastric pain.", + "The patient had tarry stool passage that lasted for 3 d.", + "The patient had a medical history of poor cardiopulmonary function.", + "The computed tomographic scan of abdomen showed cystic artery pseudoaneurysm.", + "The computed tomographic scan of abdomen showed dilatation of gallbladder.", + "The patient was successfully managed with endovascular embolization for this cystic artery pseudoaneurysm.", + "The patient was successfully managed with percutaneous drainage for the distended gallbladder." + ] + }, + { + "id": "multiclinsum_test_1327_en.txt", + "fulltext": "A 68-year-old woman was admitted to our hospital for weakness for more than 3 d.\nThree days before admission, she first experienced weakness of the limb weakness with posterior neck pain, numbness in the distal extremities, and a feeling of electric shock when touched. On the day of admission, these symptoms were aggravated, and she could not stably hold things in either hand. She also had cold-related pain in the upper extremities, weakness in the lower extremities, an inability to ambulate, urinary and fecal retention, and increased posterior neck pain. A cranial computed tomography (CT) showed no obvious signs of hemorrhage. The patient did not experience chills or fever, cough or sputum production, headache, visual hallucination, choking and coughing when eating, dysarthria, chest pain, palpitations, abdominal distension, or diarrhea.\nShe had a history of hypertension for more than one year and was taking daily amlodipine tablets. She denied any history of upper respiratory tract infection, diarrhea, or abdominal pain before the onset of symptoms and reported no recent vaccinations. She had no history of diabetes mellitus or allergy to foods or drugs.\nShe had no history of diabetes mellitus or allergy to foods or drugs. Denial of family history.\nPhysical examination: At admission, her body temperature was 36.8 ℃, her pulse rate was 76 beats/min and rhythmical, and there were no pathological murmurs in the auscultation area of each heart valve. Her respiratory rate was 20 breaths/min, her blood pressure was 145/78 mmHg, and there was no neck stiffness or breathing resistance. There were clear breath sounds in both lungs and no dry rales. Her abdomen was soft, and she had no varices in the veins of the abdominal wall. No pressure tenderness or rebound pain was observed at McBurney's point. There was no shifting dullness to percussion, but slightly reduced bowel sounds (2–3/min) were observed. Her lower limbs had no edema.\nNeurological examination: The patient had clear consciousness and no dysarthria. Her pupils were round, had the same diameter (3.0 mm), and were light-sensitive. She had adequate eye movement in all directions, no nystagmus, and symmetrical bilateral frontal lines. The muscle strength of both upper limbs was grade 4; the muscle strength of both lower limbs was grade 3; the muscle tone of the limbs was low; and the tendon reflexes had bilateral weakness. The Babinski sign was positive on both sides. Her sensations of bilateral distal pain and temperature were slightly reduced; the two-handed finger-nose test was stable and accurate; the bilateral heel-knee-shin test was unstable and inaccurate; and she had normal bilateral vibration sensation and joint position sensation. The meningeal stimulation sign was negative, and she exhibited no involuntary movements.\nThe complete blood count, liver and renal function tests, coagulation indicators, and tumor indicators indicated no significant abnormalities and cranial magnetic resonance imaging (MRI) also did not show significant abnormalities. A lumbar puncture indicated an elevated cerebrospinal fluid (CSF) pressure of 116 mmH20 and the presence of cytoalbuminologic dissociation. A peripheral neuropathy immunoblotting test (ganglioside antibody profile) was positive for anti-sulfatide antibody IgG. The markers of central nervous system demyelinating diseases, including oligoclonal bands, aquaporin 4, and anti-MOG antibodies, were all negative\nElectromyography revealed some motor nerves with conduction block but normal sensory nerve conduction velocity and wave amplitude, suggesting damage to multiple peripheral nerves. A cervical MRI revealed a high signal in the cervical spinal cord, suggesting inflammatory changes.However, a thoracic MRI revealed degeneration of certain thoracic discs, and a lumbar MRI revealed bulges of the L3/4, L4/5, and L5/S1 discs. A chest CT revealed two foci of lung fibrosis, but a whole abdominal CT did not reveal significant abnormalities", + "fulltext_subclaims": [ + "The patient was a 68-year-old woman.", + "She was admitted to the hospital for weakness for more than 3 d.", + "Three days before admission, she first experienced limb weakness with posterior neck pain.", + "Three days before admission, she had numbness in the distal extremities.", + "Three days before admission, she had a feeling of electric shock when touched.", + "On the day of admission, these symptoms were aggravated.", + "On the day of admission, she could not stably hold things in either hand.", + "She had cold-related pain in the upper extremities.", + "She had weakness in the lower extremities.", + "She had an inability to ambulate.", + "She had urinary and fecal retention.", + "She had increased posterior neck pain.", + "A cranial CT showed no obvious signs of hemorrhage.", + "She did not experience chills or fever.", + "She did not experience cough or sputum production.", + "She did not experience headache.", + "She did not experience visual hallucination.", + "She did not experience choking and coughing when eating.", + "She did not experience dysarthria.", + "She did not experience chest pain.", + "She did not experience palpitations.", + "She did not experience abdominal distension.", + "She did not experience diarrhea.", + "She had a history of hypertension for more than one year.", + "She was taking daily amlodipine tablets.", + "She denied any history of upper respiratory tract infection before the onset of symptoms.", + "She denied any history of diarrhea before the onset of symptoms.", + "She denied any history of abdominal pain before the onset of symptoms.", + "She reported no recent vaccinations.", + "She had no history of diabetes mellitus.", + "She had no allergy to foods or drugs.", + "She had no family history.", + "At admission, her body temperature was 36.8 ℃.", + "Her pulse rate was 76 beats/min and rhythmical.", + "There were no pathological murmurs in the auscultation area of each heart valve.", + "Her respiratory rate was 20 breaths/min.", + "Her blood pressure was 145/78 mmHg.", + "There was no neck stiffness.", + "There was no breathing resistance.", + "There were clear breath sounds in both lungs.", + "There were no dry rales.", + "Her abdomen was soft.", + "There was no varices in the veins of the abdominal wall.", + "There was no pressure tenderness at McBurney's point.", + "There was no rebound pain at McBurney's point.", + "There was no shifting dullness to percussion.", + "Bowel sounds were slightly reduced (2–3/min).", + "Her lower limbs had no edema.", + "The patient had clear consciousness.", + "She had no dysarthria.", + "Her pupils were round.", + "Her pupils had the same diameter (3.0 mm).", + "Her pupils were light-sensitive.", + "She had adequate eye movement in all directions.", + "She had no nystagmus.", + "She had symmetrical bilateral frontal lines.", + "The muscle strength of both upper limbs was grade 4.", + "The muscle strength of both lower limbs was grade 3.", + "The muscle tone of the limbs was low.", + "The tendon reflexes had bilateral weakness.", + "The Babinski sign was positive on both sides.", + "Her sensations of bilateral distal pain and temperature were slightly reduced.", + "The two-handed finger-nose test was stable and accurate.", + "The bilateral heel-knee-shin test was unstable and inaccurate.", + "She had normal bilateral vibration sensation.", + "She had normal bilateral joint position sensation.", + "The meningeal stimulation sign was negative.", + "She exhibited no involuntary movements.", + "The complete blood count indicated no significant abnormalities.", + "The liver and renal function tests indicated no significant abnormalities.", + "The coagulation indicators indicated no significant abnormalities.", + "The tumor indicators indicated no significant abnormalities.", + "Cranial MRI did not show significant abnormalities.", + "A lumbar puncture indicated an elevated cerebrospinal fluid pressure of 116 mmH2O.", + "The lumbar puncture showed the presence of cytoalbuminologic dissociation.", + "The peripheral neuropathy immunoblotting test was positive for anti-sulfatide antibody IgG.", + "The markers of central nervous system demyelinating diseases were all negative.", + "Electromyography revealed some motor nerves with conduction block.", + "Electromyography showed normal sensory nerve conduction velocity.", + "Electromyography showed normal sensory nerve wave amplitude.", + "Electromyography suggested damage to multiple peripheral nerves.", + "Cervical MRI revealed a high signal in the cervical spinal cord.", + "Cervical MRI suggested inflammatory changes.", + "Thoracic MRI revealed degeneration of certain thoracic discs.", + "Lumbar MRI revealed bulges of the L3/4, L4/5, and L5/S1 discs.", + "Chest CT revealed two foci of lung fibrosis.", + "Whole abdominal CT did not reveal significant abnormalities." + ], + "summary": "A 68-year-old woman was admitted to the hospital with weakness of the limb for more than 3 d. Additional symptoms included neck pain, progressive numbness in the distal extremities, urinary and fecal retention, and reduced perception of temperature. She was diagnosed with an anti-sulfatide antibody-positive GBS variant and discharged after treatment with methylprednisolone and intravenous human immunoglobulin pulse therapy. Unlike common cases of anti-sulfatide antibody-positive GBS, this patient had atypical clinical symptoms of spinal cord involvement. No similar cases have previously been reported in China.", + "summary_subclaims": [ + "A 68-year-old woman was admitted to the hospital with weakness of the limb for more than 3 d.", + "Additional symptoms included neck pain.", + "Additional symptoms included progressive numbness in the distal extremities.", + "Additional symptoms included urinary and fecal retention.", + "Additional symptoms included reduced perception of temperature.", + "She was diagnosed with an anti-sulfatide antibody-positive GBS variant.", + "She was discharged after treatment with methylprednisolone and intravenous human immunoglobulin pulse therapy.", + "This patient had atypical clinical symptoms of spinal cord involvement.", + "No similar cases have previously been reported in China." + ] + }, + { + "id": "multiclinsum_test_2641_en.txt", + "fulltext": "We hereby present the case of a 72-year-old woman with an extended cSCC of the leg with tibial infiltration, developed on a chronic ulcer that developed on top of NL, without diabetes mellitus . Eighteen years before, the patient had developed the same condition on the contralateral leg and a below the knee amputation had been performed. After biopsy for confirmation and staging including whole body CT scan and regional lymph node sonography, the tumor board recommended the curative resection of the localized tumor. A curative en bloc resection of the tumor together with the soft tissue and 15 cm of involved tibia was performed . A polymethyl methacrylate (PMMA) spacer was used to bridge the tibia and an external fixator stabilized the leg . The wound was temporarily closed using negative wound pressure therapy (NPWT). The histopathological findings showed macroscopically a 165 × 152-mm large tumor, microscopically with 22-mm invasion of the fatty tissue and 10-mm invasion of the tibia, with a at least 18-mm tumor-free margin on the surface and at least 5 mm deep (pT4a, pNx, L0, V0, Pn0, G2, R0) . After achieving the R0 resection, a reconstruction plan was developed. Digital subtraction angiography was performed, showing a three-vessel supply of the leg. Being the only leg in an otherwise healthy patient who was mobile with a leg prosthesis on the right side, the indication for limb preservation was established. Seven days after the first surgery, the reconstructive surgery took place. The PMMA spacer was removed and a proximal pedicled fibular bone flap was harvested. The bone length was 18 cm. The bone ends were then beveled to fit the tibial medullary cavity and the fibula was then press-fitted in the tibia, reconstructing the 15-cm bone gap with 1.5 cm of fibula lying proximally and distally in the tibia . Two centimeters of proximal fibula was resected to ensure a tension-free pedicle positioning. A plate and screw osteosynthesis was performed, bridging the fibula graft, but fixating the beveled edges to the tibia. The external fixator was now removed. The muscles of the anterior and lateral compartment remained supplied by the anterior tibial vascular pedicle. The remaining soft tissue defect of 26 × 20 cm was measured and a template was transferred to the right thigh, centered on the descending branch of the lateral circumflex femoral artery. An extended ALT fasciocutaneous flap measuring 26 × 14 cm including two perforator vessels was harvested. The vessel anastomosis at the recipient site was performed to the anterior tibial artery as a flow-through flap and to the venae commitantes using vessel couplers . The medially exposed gastrocnemius muscle was split skin grafted . The donor site was also split skin grafted from the contralateral side. Postoperatively antibiotic treatment was initiated. The distal part of the flap (8 × 4 cm) showed a demarcation due to inadequate perfusion . At revision surgery, after flap debridement, pus emptied from the plate surroundings. A thorough debridement with lavage of the site was performed. NPWT was used for one cycle to control the infection. Bacteroides fragilis could be isolated and the antibiotics were adapted to the antibiogram. At the next surgery, further debridement and lavage with the exchange of the plate and screws was performed. The remaining soft tissue defect was covered with a second ALT flap measuring 16 × 7 cm from the left thigh, including the fresh split skin donor sites, using two perforator vessels . The flap anastomosis was performed end-to-side to the posterior tibial vessels, distal to the first anastomosis. The donor site was closed primarily. Postoperatively, all wounds showed primary healing. The antibiotics were administered for a total of 6 weeks starting from the last surgery. After 4 weeks, mobilization with partial weight-bearing of the leg was initiated. Twelve weeks postoperatively, ambulation using a wheeled walker was started.\nOne year postoperatively, the CT scan showed insufficient bony consolidation at the proximal and distal tibia-fibula transition despite exogenic ultrasound therapy, so a revisional surgery was performed. The extended ALT flap was longitudinally split to provide access to the plate while avoiding the lesion of the vascular pedicle. Two osteosynthesis plates were used to stabilize the leg medially and laterally and to ensure bone consolidation. Autologous cancellous bone was applied at the transition between the fibula and tibia proximally and distally. Postoperatively, the wounds healed without issues. After 6 weeks, mobilization of the leg was started using a fitted boot with pressure distribution to the tibial tuberosity and the foot. After 3 months postoperatively, the exogenic ultrasound therapy was continued for another 3 months. The pressure distribution was progressively switched from the tibial tuberosity to the foot.\nTwo years after the beginning of treatment, the boot was completely removed. The patient was mobile on the reconstructed leg and below-the-knee prosthesis on the contralateral side . The extension of the foot was actively possible (Video 1). The X-rays and CT-scan showed a fibular hypertrophy of about 90% of the tibia as well as no local recurrence of the tumor and no metastasis. Considering the age of the patient, R0 resection of the lesion, no lymph node metastasis or other metastasis, no adjuvant therapy was performed.", + "fulltext_subclaims": [ + "The patient is a 72-year-old woman.", + "She has an extended cSCC of the leg with tibial infiltration.", + "The cSCC developed on a chronic ulcer that developed on top of NL.", + "She does not have diabetes mellitus.", + "Eighteen years before, the patient had the same condition on the contralateral leg.", + "A below the knee amputation had been performed on the contralateral leg.", + "After biopsy, staging included whole body CT scan and regional lymph node sonography.", + "The tumor board recommended curative resection of the localized tumor.", + "A curative en bloc resection of the tumor together with the soft tissue and 15 cm of involved tibia was performed.", + "A polymethyl methacrylate (PMMA) spacer was used to bridge the tibia.", + "An external fixator stabilized the leg.", + "The wound was temporarily closed using negative wound pressure therapy (NPWT).", + "The histopathological findings showed a 165 × 152-mm large tumor.", + "The tumor had 22-mm invasion of the fatty tissue.", + "The tumor had 10-mm invasion of the tibia.", + "The tumor-free margin on the surface was at least 18 mm.", + "The tumor-free margin deep was at least 5 mm.", + "The histopathological classification was pT4a, pNx, L0, V0, Pn0, G2, R0.", + "After achieving the R0 resection, a reconstruction plan was developed.", + "Digital subtraction angiography showed a three-vessel supply of the leg.", + "The indication for limb preservation was established.", + "Seven days after the first surgery, the reconstructive surgery took place.", + "The PMMA spacer was removed.", + "A proximal pedicled fibular bone flap was harvested.", + "The bone length was 18 cm.", + "The bone ends were beveled to fit the tibial medullary cavity.", + "The fibula was press-fitted in the tibia.", + "The external fixator was removed.", + "The muscles of the anterior and lateral compartment remained supplied by the anterior tibial vascular pedicle.", + "An extended ALT fasciocutaneous flap measuring 26 × 14 cm was harvested.", + "The vessel anastomosis was performed to the anterior tibial artery as a flow-through flap.", + "The vessel anastomosis was also performed to the venae commitantes using vessel couplers.", + "The medially exposed gastrocnemius muscle was split skin grafted.", + "The donor site was also split skin grafted from the contralateral side.", + "Postoperatively, antibiotic treatment was initiated.", + "The distal part of the flap showed a demarcation due to inadequate perfusion.", + "At revision surgery, after flap debridement, pus emptied from the plate surroundings.", + "A thorough debridement with lavage of the site was performed.", + "NPWT was used for one cycle to control the infection.", + "Bacteroides fragilis could be isolated.", + "The antibiotics were adapted to the antibiogram.", + "At the next surgery, further debridement and lavage with the exchange of the plate and screws was performed.", + "The remaining soft tissue defect was covered with a second ALT flap measuring 16 × 7 cm from the left thigh.", + "The flap anastomosis was performed end-to-side to the posterior tibial vessels, distal to the first anastomosis.", + "The donor site was closed primarily.", + "Postoperatively, all wounds showed primary healing.", + "The antibiotics were administered for a total of 6 weeks starting from the last surgery.", + "After 4 weeks, mobilization with partial weight-bearing of the leg was initiated.", + "Twelve weeks postoperatively, ambulation using a wheeled walker was started.", + "One year postoperatively, the CT scan showed insufficient bony consolidation at the proximal and distal tibia-fibula transition.", + "A revisional surgery was performed.", + "The extended ALT flap was longitudinally split to provide access to the plate.", + "Two osteosynthesis plates were used to stabilize the leg medially and laterally.", + "Autologous cancellous bone was applied at the transition between the fibula and tibia proximally and distally.", + "Postoperatively, the wounds healed without issues.", + "After 6 weeks, mobilization of the leg was started using a fitted boot.", + "After 3 months postoperatively, the exogenic ultrasound therapy was continued for another 3 months.", + "The pressure distribution was progressively switched from the tibial tuberosity to the foot.", + "Two years after the beginning of treatment, the boot was completely removed.", + "The patient was mobile on the reconstructed leg and below-the-knee prosthesis on the contralateral side.", + "The extension of the foot was actively possible.", + "The X-rays and CT-scan showed a fibular hypertrophy of about 90% of the tibia.", + "There was no local recurrence of the tumor.", + "There were no metastases.", + "Considering the age of the patient, R0 resection of the lesion, no lymph node metastasis or other metastasis, no adjuvant therapy was performed." + ], + "summary": "We present the case of a 72-year-old female patient presenting with an extended cutaneous squamous cell carcinoma of the lower leg, developed on top of necrobiosis lipoidica. After achieving the R0 resection, a 26 × 20-cm soft tissue and 15-cm tibial bone defect resulted. The contralateral leg had been lost due to the same disease 18 years before. We achieved a successful reconstruction of the leg using a pedicled fibula transplantation, an extended anterolateral thigh perforator flap, and an internal fixation with plate and screws. Two years after the original surgery, the patient is relapse-free and mobile, with adequate function of the reconstructed foot.", + "summary_subclaims": [ + "The patient is a 72-year-old female.", + "The patient had an extended cutaneous squamous cell carcinoma of the lower leg.", + "The squamous cell carcinoma developed on top of necrobiosis lipoidica.", + "The patient achieved R0 resection.", + "A 26 × 20-cm soft tissue defect resulted after resection.", + "A 15-cm tibial bone defect resulted after resection.", + "The contralateral leg had been lost due to the same disease 18 years before.", + "The leg was reconstructed using a pedicled fibula transplantation.", + "The leg was reconstructed using an extended anterolateral thigh perforator flap.", + "The leg was reconstructed using internal fixation with plate and screws.", + "Two years after the original surgery, the patient is relapse-free.", + "Two years after the original surgery, the patient is mobile.", + "Two years after the original surgery, the patient has adequate function of the reconstructed foot." + ] + }, + { + "id": "multiclinsum_test_886_en.txt", + "fulltext": "This Chinese patient was 59 years old. He was healthy before, without history of thrombosis. When he was admitted to our hospital, CT examination showed a mass in the right kidney, and there was no sign of infection. However, the subsequent CT angiography showed that the mass in the right kidney had abundant blood supply, and there was thrombosis in the right renal vein. Near the left renal vein there was another mass, but there were no thrombi in the left renal vein and portal vein . The entire right kidney and the mass in the left kidney were excised by surgeons, and histological examination suggested WHO/ISUP grade-3 clear cell carcinoma. Post-operatively, he developed acute kidney injury (AKI) as evidenced by decreased urine volume (0.27 ml/h/kg for 3 h) and increased serum creatinine (75 mol/l higher than the preoperative level), and selective left renal venography showed a 2 cm filling defect in the left renal vein, suggesting thrombosis . After the thrombus was removed, we performed continuous venovenous hemodiafiltration (CVVHDF) on the patient. Within the first 12 h, the patient was conscious, with stable vital signs. In addition, he had no fever, and the urine volume exceeded 40 ml/h, indicating that AKI was prerenal AKI caused by the thrombus in his left renal vein. Thus, he improved quickly after thrombectomy.\nHowever, in the following 12 h, the patient showed signs of infection. His consciousness became poor, while body temperature and heart rate increased, and blood pressure, urine volume and oxygenation index decreased. The high CRP (71.82 mg/l) and PCT (22.82 ng/ml) levels also suggested that the patient might be infected. Based on the 2016 SSC guidelines, the patient had septic shock. In addition, SOFA score and laboratory test results were deteriorating . Therefore, we immediately started fluid resuscitation, drew the patient's blood for culture, and empirically commenced meropenem and teicoplanin for treatment of the suspected sepsis.\nUnfortunately, he continued to deteriorate such that by the second day his respiratory and circulatory systems collapsed and he required ventilation with almost pure oxygen. He died on the third day of respiratory and circulatory failure, and the result of the blood culture, which was received two days later, showed that he had F. nucleatum bacteremia, sensitive to penicillin, cefoxitin, piperacillin/tazobactam, cefoperazone/sulbactam, imipenem/cilastatin, meropenem, clindamycin and metronidazole, intermediate to ceftriaxone, and resistant to none.", + "fulltext_subclaims": [ + "This Chinese patient was 59 years old.", + "He was healthy before, without history of thrombosis.", + "CT examination showed a mass in the right kidney.", + "There was no sign of infection.", + "The mass in the right kidney had abundant blood supply.", + "There was thrombosis in the right renal vein.", + "There was another mass near the left renal vein.", + "There were no thrombi in the left renal vein.", + "There were no thrombi in the portal vein.", + "The entire right kidney and the mass in the left kidney were excised.", + "Histological examination suggested WHO/ISUP grade-3 clear cell carcinoma.", + "Post-operatively, he developed acute kidney injury.", + "Acute kidney injury was evidenced by decreased urine volume (0.27 ml/h/kg for 3 h).", + "Acute kidney injury was evidenced by increased serum creatinine (75 mol/l higher than the preoperative level).", + "Selective left renal venography showed a 2 cm filling defect in the left renal vein.", + "The filling defect suggested thrombosis.", + "The thrombus was removed.", + "CVVHDF was performed on the patient.", + "Within the first 12 h, the patient was conscious.", + "Within the first 12 h, the patient had stable vital signs.", + "The patient had no fever.", + "The urine volume exceeded 40 ml/h.", + "AKI was prerenal AKI caused by the thrombus in his left renal vein.", + "He improved quickly after thrombectomy.", + "In the following 12 h, the patient showed signs of infection.", + "His consciousness became poor.", + "Body temperature increased.", + "Heart rate increased.", + "Blood pressure decreased.", + "Oxygenation index decreased.", + "CRP was 71.82 mg/l.", + "PCT was 22.82 ng/ml.", + "The patient had septic shock.", + "Fluid resuscitation was started.", + "Blood was drawn for culture.", + "Empirical meropenem and teicoplanin were commenced.", + "By the second day, the patient's respiratory and circulatory systems collapsed.", + "He required ventilation with almost pure oxygen.", + "He died on the third day.", + "The cause of death was respiratory and circulatory failure.", + "Blood culture showed F. nucleatum bacteremia.", + "F. nucleatum was sensitive to penicillin.", + "F. nucleatum was sensitive to cefoxitin.", + "F. nucleatum was sensitive to piperacillin/tazobactam.", + "F. nucleatum was sensitive to cefoperazone/sulbactam.", + "F. nucleatum was sensitive to imipenem/cilastatin.", + "F. nucleatum was sensitive to meropenem.", + "F. nucleatum was sensitive to clindamycin.", + "F. nucleatum was sensitive to metronidazole.", + "F. nucleatum was intermediate to ceftriaxone.", + "F. nucleatum was resistant to none." + ], + "summary": "This patient had kidney cancer with thrombosis in the right renal vein but had no sign of infection. After radical nephrectomy, thrombi formed in his left renal vein, and when removed, severe sepsis occurred. He did not respond to treatment with antibiotics and died, but the blood culture done confirmed that he had F. nucleatum bacteremia.", + "summary_subclaims": [ + "This patient had kidney cancer with thrombosis in the right renal vein.", + "He had no sign of infection.", + "After radical nephrectomy, thrombi formed in his left renal vein.", + "When removed, severe sepsis occurred.", + "He did not respond to treatment with antibiotics and died.", + "The blood culture done confirmed that he had F. nucleatum bacteremia." + ] + }, + { + "id": "multiclinsum_test_565_en.txt", + "fulltext": "The subject was a 53-year-old housewife, who consulted in December 2013 for inflammatory pain in the right hip evolving for 3 months controlled with non-steroidal anti-inflammatory drugs, with a walking distance of about 100 m. The medical history revealed that she is HIV infected and on triple ARV for 1 year, with a CD4 count of 473/ml, the viral load was not documented. Evaluation of the right hip showed flexion/extension of 80/20, abduction/adduction of 40/20, internal rotation/external rotation of 20/15, a trendelenburg gait, and a limb length discrepancy of 3 cm. The muscle power of the gluteus medius was 4/5. There was amyotrophy of the right quadriceps muscle. The Merle d’Aubigne and postel hip score was evaluated to be 9/18. The anterior-posterior view of the pelvic X-ray shows joint space narrowing, loss of head sphericity, shortened hip length, with no other signs of coxarthrosis (sclerosis, geodes, osteophytes). These findings coupled with the patient’s history of immunosuppression were suggestive of a coxitis, which could be due to tuberculosis (TB) infection. However, an MRI scan was not done because it was unavailable, and the patient could not afford to do it due to financial constraints. The full blood count revealed a hemoglobin level of 13 g/dl, however, the white cell count was 8000 with 45% lymphocytes and 50% neutrophiles. The rest of the laboratory investigation was unremarkable.\nThe patient was operated for implantation of a THA via the Hardinge approach. During surgery, an incident was encountered while dislocating the hip to resect the femoral head. There was a cream-white liquid that was oozing out of the hip joint . A sample was rapidly collected per-operative and sent for urgent bacteriological analysis. The gram coloration was negative, the rest of the liquid was then sent for microbiological, mycobacteriological and histological analyses. The debris from reaming and the femoral head were also sent for analysis. The surgery was continued and completed with the implantation of a hybrid THA due to the fragile acetabulum; the stem was uncemented while the acetabulum was cemented . The anatomopathological findings showed an active TB infection . At the end of the surgery, the limb length discrepancy was corrected. The wound healing was normal, and rehabilitation commenced 24 h after surgery with isometric contractions of the gluteal and quadriceps muscles in bed. She was then verticalized the second day following surgery and walking was assisted using crutches. The patient thence continued with her ARV the same day of surgery and 10 days triple antibiotics initiated. She had a fixed combination of antituberculous drugs (isoniazid, rifampin, pyrazinamide, and ethambutol) to be taken for 12 months. 3 years after the surgery we have not noticed any relapse of the infection or any loosening.", + "fulltext_subclaims": [ + "The subject was a 53-year-old housewife.", + "She consulted in December 2013 for inflammatory pain in the right hip.", + "The pain had been evolving for 3 months.", + "The pain was controlled with non-steroidal anti-inflammatory drugs.", + "Her walking distance was about 100 m.", + "She is HIV infected.", + "She was on triple ARV for 1 year.", + "Her CD4 count was 473/ml.", + "The viral load was not documented.", + "Evaluation of the right hip showed flexion/extension of 80/20.", + "Evaluation showed abduction/adduction of 40/20.", + "Evaluation showed internal rotation/external rotation of 20/15.", + "There was a trendelenburg gait.", + "There was a limb length discrepancy of 3 cm.", + "The muscle power of the gluteus medius was 4/5.", + "There was amyotrophy of the right quadriceps muscle.", + "The Merle d’Aubigne and postel hip score was 9/18.", + "The anterior-posterior view of the pelvic X-ray showed joint space narrowing.", + "The anterior-posterior view showed loss of head sphericity.", + "The anterior-posterior view showed shortened hip length.", + "There were no signs of coxarthrosis (sclerosis, geodes, osteophytes).", + "These findings were suggestive of a coxitis.", + "The coxitis could be due to tuberculosis.", + "An MRI scan was not done because it was unavailable.", + "The patient could not afford the MRI scan.", + "The full blood count revealed a hemoglobin level of 13 g/dl.", + "The white cell count was 8000.", + "The white cell count showed 45% lymphocytes.", + "The white cell count showed 50% neutrophiles.", + "The rest of the laboratory investigation was unremarkable.", + "The patient was operated for implantation of a THA via the Hardinge approach.", + "An incident was encountered during dislocation of the hip.", + "A cream-white liquid was oozing out of the hip joint.", + "A sample was collected per-operative and sent for urgent bacteriological analysis.", + "The gram coloration was negative.", + "The rest of the liquid was sent for microbiological analysis.", + "The rest of the liquid was sent for mycobacteriological analysis.", + "The rest of the liquid was sent for histological analyses.", + "The debris from reaming was sent for analysis.", + "The femoral head was sent for analysis.", + "The surgery was continued with the implantation of a hybrid THA.", + "The stem was uncemented.", + "The acetabulum was cemented.", + "The anatomopathological findings showed an active TB infection.", + "The limb length discrepancy was corrected.", + "The wound healing was normal.", + "Rehabilitation commenced 24 h after surgery.", + "Rehabilitation included isometric contractions of the gluteal and quadriceps muscles in bed.", + "The patient was verticalized the second day following surgery.", + "Walking was assisted using crutches.", + "She continued with her ARV the same day of surgery.", + "She had 10 days of triple antibiotics initiated.", + "She was given a fixed combination of antituberculous drugs.", + "The antituberculous drugs included isoniazid, rifampin, pyrazinamide, and ethambutol.", + "The antituberculous drugs were to be taken for 12 months.", + "3 years after the surgery, there was no relapse of the infection.", + "3 years after the surgery, there was no loosening." + ], + "summary": "The patient was a 53-year-old Black African woman, positive for the HIV, who was operated for implantation of a THA via the Hardinge approach indicated for a severe painful hip with restriction of joint movement and limp. A creamy-white liquid was noticed in the hip joint which was negative for urgent Gram-staining. The surgery was completed with the implantation of a hybrid THA. The post-operative period was uneventful, and she was put on antituberculous drugs following a positive histology result for TB, and to continue her antiretroviral drugs. She still has a satisfactory result for 3 years since her surgery.", + "summary_subclaims": [ + "The patient was a 53-year-old Black African woman.", + "The patient was positive for the HIV.", + "The patient was operated for implantation of a THA via the Hardinge approach.", + "The indication was a severe painful hip with restriction of joint movement and limp.", + "A creamy-white liquid was noticed in the hip joint.", + "The liquid was negative for urgent Gram-staining.", + "The surgery was completed with the implantation of a hybrid THA.", + "The post-operative period was uneventful.", + "She was put on antituberculous drugs following a positive histology result for TB.", + "She was to continue her antiretroviral drugs.", + "She still has a satisfactory result for 3 years since her surgery." + ] + }, + { + "id": "multiclinsum_test_2354_en.txt", + "fulltext": "A 22-year-old Caucasian lady presented in 2014 with features of pulmonary fibrosis, chronic cutaneous problems, and symmetrical polyarthritis. She had previously been well without any comorbidities. A high-resolution computed tomography (CT) chest and lung biopsy were performed, with a diagnosis of hypersensitivity pneumonitis being made, in the context of significant mould exposure. Skin biopsies demonstrated spongiotic dermatitis (eczema). Echocardiography revealed right ventricular dilatation with mild tricuspid regurgitation. Left ventricular size and function was normal.\nShe was discharged and attended as an outpatient to a specialist centre for pulmonary hypertension, as it was assumed at the time that the right ventricular dilatation was a consequence of undiagnosed pulmonary hypertension. Here, right heart catheterization indicated normal pulmonary arterial pressure. Subsequently, no cardiology follow-up was arranged. The patient was treated with methotrexate, sulfasalazine, and intermittent prednisone over the next 4 years, although a single unifying diagnosis to explain her all of her symptoms was not identified.\nIn 2018, the patient attended a rheumatology clinic. The rheumatologist was concerned that there were clinical signs of pulmonary hypertension detected on physical examination, and thus a routine echocardiogram was performed. This study demonstrated severe right ventricular dilatation . There was now severe tricuspid valve regurgitation . The left ventricular size was normal, as was systolic and diastolic left ventricular function. There was no significant left-sided valvular disease. The patient was experiencing dyspnoea on walking 50 m on a flat surface, or at the top of a single flight of stairs. Additionally, she described four episodes of unheralded syncope, all occurring whilst seated. On physical examination, the blood pressure was 130/70 mmHg, the heart rate 88 b.p.m., and regular, with oxygen saturation of 99% on room air. The jugular venous pressure was elevated with prominent V waves. There was a right ventricular heave and a loud pan-systolic murmur audible at the left sternal edge. Pulsatile hepatomegaly was present. Fine crackles were present in both lung bases. Electrocardiogram demonstrated atrial fibrillation with a right bundle branch block .\nDue to the concerning features on echocardiography and the symptoms of dyspnoea and syncope, the patient was admitted to a monitored cardiac ward for further investigation. Telemetry demonstrated non-sustained ventricular tachycardia (VT) at a rate of 150 b.p.m. , of which the patient was symptomatic with palpitations but there was no haemodynamic compromise.\nRight heart catheterization revealed normal pulmonary arterial pressures (22/10 mmHg), but elevated right atrial pressures (16/14 mmHg). Cardiac output (5.4 L/min) and pulmonary vascular resistance (88 dynes.s/cm5) were normal.\nThe patient underwent transoesophageal echocardiography (TOE) and successful electrical cardioversion, restoring sinus rhythm. The TOE excluded atrial thrombus, any intracardiac left-to-right shunt, and all four pulmonary veins communicated with the left atrium.\nCardiac magnetic resonance imaging (MRI) did not show any late gadolinium enhancement in either ventricle, and congenital anatomical anomalies were excluded. Cardiac positron emission tomography ( PET) did not reveal increased metabolic activity to indicate inflammation or features of active cardiac sarcoidosis. A CT chest demonstrated unchanged features of pulmonary fibrosis.\nMyocardial biopsy was performed under fluoroscopic guidance. Histopathology revealed a predominantly lymphocytic chronic inflammatory infiltrate . A single well-formed small granuloma as well as a second focus of scattered giant cells was noted. Moderate to severe myopathic features were seen, including myocyte necrosis with features of myocytolysis and anisonucleosis, and patchy regenerative interstitial fibrosis. The diagnosis was consistent with lymphocytic myocarditis. The morphological pattern that comprised myocyte necrosis and a widespread lymphocytic infiltrate without predominating giant cells and granulomas was less likely to be consistent with cardiac sarcoidosis or giant cell myocarditis. There was a paucity of eosinophils, making the diagnosis of hypersensitivity myocarditis highly unlikely. The classic features of arrhythmogenic cardiomyopathy (AC) were also not seen, i.e. patchy to diffuse irregular replacement of myocytes by adipose tissue, with associated variable amounts of fibrosis, lack of significant lymphocytic infiltrate, and scattered enlarged degenerate vacuolated myocytes. A broad range of serological investigations had also been conducted, with no significant positive results.\nGiven the documented symptomatic VT, and the history of syncope, the patient was referred for a cardiac electrophysiology study, which demonstrated inducible VT originating from the RV apex that lasted for over 30 s. Following a multidisciplinary discussion, the patient consented to the implantation of an automated implantable cardioverter-defibrillator (AICD).\nThe patient was commenced on prednisone 25 mg daily, as well as sotalol 80 mg twice daily and apixaban 5 mg twice daily, prior to discharge. Since discharge, her prednisone has been ceased after being systematically weaned following commencement of azathioprine 100 mg daily. She has been stable thereafter, with no further arrhythmias and has returned to work. Occasional episodes of decompensated mild right heart failure have been treated successfully with oral diuretics, without the need for intravenous therapy or inpatient admission. An echocardiogram performed 12 months after discharge revealed a marginal improvement in right ventricular function, with residual severe tricuspid regurgitation. As the overall clinical condition of the patient has remained stable, repeat myocardial biopsy was not performed.\nThe process is considered chronic based on the first detection of right ventricular abnormalities 4 years prior. In addition, the chronic inflammatory infiltrate and interstitial fibrosis supports this conclusion.\nThus, we describe a case of an immunosuppressed young lady who was suffering from a chronic low-grade lymphocytic myocarditis of the RV resulting in dilatation of the chamber, severe functional tricuspid regurgitation, and arrhythmic complications including atrial fibrillation and VT. All cardiac imaging modalities demonstrated normal left ventricular size and function, suggesting this process demonstrated a preponderance to the RV.", + "fulltext_subclaims": [ + "A 22-year-old Caucasian lady presented in 2014 with features of pulmonary fibrosis, chronic cutaneous problems, and symmetrical polyarthritis.", + "She had previously been well without any comorbidities.", + "A high-resolution computed tomography (CT) chest and lung biopsy were performed.", + "A diagnosis of hypersensitivity pneumonitis was made in the context of significant mould exposure.", + "Skin biopsies demonstrated spongiotic dermatitis (eczema).", + "Echocardiography revealed right ventricular dilatation with mild tricuspid regurgitation.", + "Left ventricular size and function was normal.", + "She was discharged and attended as an outpatient to a specialist centre for pulmonary hypertension.", + "Right heart catheterization indicated normal pulmonary arterial pressure.", + "No cardiology follow-up was arranged.", + "The patient was treated with methotrexate, sulfasalazine, and intermittent prednisone over the next 4 years.", + "A single unifying diagnosis to explain all of her symptoms was not identified.", + "In 2018, the patient attended a rheumatology clinic.", + "The rheumatologist was concerned that there were clinical signs of pulmonary hypertension detected on physical examination.", + "A routine echocardiogram was performed.", + "This study demonstrated severe right ventricular dilatation.", + "There was now severe tricuspid valve regurgitation.", + "The patient was experiencing dyspnoea on walking 50 m on a flat surface, or at the top of a single flight of stairs.", + "She described four episodes of unheralded syncope, all occurring whilst seated.", + "On physical examination, the blood pressure was 130/70 mmHg, the heart rate 88 b.p.m., and regular, with oxygen saturation of 99% on room air.", + "The jugular venous pressure was elevated with prominent V waves.", + "There was a right ventricular heave and a loud pan-systolic murmur audible at the left sternal edge.", + "Pulsatile hepatomegaly was present.", + "Fine crackles were present in both lung bases.", + "Electrocardiogram demonstrated atrial fibrillation with a right bundle branch block.", + "The patient was admitted to a monitored cardiac ward for further investigation.", + "Telemetry demonstrated non-sustained ventricular tachycardia (VT) at a rate of 150 b.p.m., of which the patient was symptomatic with palpitations but there was no haemodynamic compromise.", + "Right heart catheterization revealed normal pulmonary arterial pressures (22/10 mmHg), but elevated right atrial pressures (16/14 mmHg).", + "Cardiac output (5.4 L/min) and pulmonary vascular resistance (88 dynes.s/cm5) were normal.", + "The patient underwent transoesophageal echocardiography (TOE) and successful electrical cardioversion, restoring sinus rhythm.", + "The TOE excluded atrial thrombus, any intracardiac left-to-right shunt, and all four pulmonary veins communicated with the left atrium.", + "Cardiac magnetic resonance imaging (MRI) did not show any late gadolinium enhancement in either ventricle, and congenital anatomical anomalies were excluded.", + "Cardiac positron emission tomography (PET) did not reveal increased metabolic activity to indicate inflammation or features of active cardiac sarcoidosis.", + "A CT chest demonstrated unchanged features of pulmonary fibrosis.", + "Myocardial biopsy was performed under fluoroscopic guidance.", + "Histopathology revealed a predominantly lymphocytic chronic inflammatory infiltrate.", + "A single well-formed small granuloma as well as a second focus of scattered giant cells was noted.", + "Moderate to severe myopathic features were seen, including myocyte necrosis with features of myocytolysis and anisonucleosis, and patchy regenerative interstitial fibrosis.", + "The diagnosis was consistent with lymphocytic myocarditis.", + "The morphological pattern that comprised myocyte necrosis and a widespread lymphocytic infiltrate without predominating giant cells and granulomas was less likely to be consistent with cardiac sarcoidosis or giant cell myocarditis.", + "There was a paucity of eosinophils, making the diagnosis of hypersensitivity myocarditis highly unlikely.", + "The classic features of arrhythmogenic cardiomyopathy (AC) were also not seen.", + "A broad range of serological investigations had also been conducted, with no significant positive results.", + "Given the documented symptomatic VT, and the history of syncope, the patient was referred for a cardiac electrophysiology study, which demonstrated inducible VT originating from the RV apex that lasted for over 30 s.", + "Following a multidisciplinary discussion, the patient consented to the implantation of an automated implantable cardioverter-defibrillator (AICD).", + "The patient was commenced on prednisone 25 mg daily, as well as sotalol 80 mg twice daily and apixaban 5 mg twice daily, prior to discharge.", + "Since discharge, her prednisone has been ceased after being systematically weaned following commencement of azathioprine 100 mg daily.", + "She has been stable thereafter, with no further arrhythmias and has returned to work.", + "Occasional episodes of decompensated mild right heart failure have been treated successfully with oral diuretics, without the need for intravenous therapy or inpatient admission.", + "An echocardiogram performed 12 months after discharge revealed a marginal improvement in right ventricular function, with residual severe tricuspid regurgitation.", + "As the overall clinical condition of the patient has remained stable, repeat myocardial biopsy was not performed.", + "The process is considered chronic based on the first detection of right ventricular abnormalities 4 years prior.", + "The chronic inflammatory infiltrate and interstitial fibrosis supports this conclusion.", + "We describe a case of an immunosuppressed young lady who was suffering from a chronic low-grade lymphocytic myocarditis of the RV resulting in dilatation of the chamber, severe functional tricuspid regurgitation, and arrhythmic complications including atrial fibrillation and VT.", + "All cardiac imaging modalities demonstrated normal left ventricular size and function, suggesting this process demonstrated a preponderance to the RV." + ], + "summary": "A 26-year-old lady was admitted to hospital following routine echocardiography, requested for screening of pulmonary hypertension in the context of known hypersensitivity pneumonitis. This echocardiogram demonstrated severe right ventricular dilatation and impairment. She was also experiencing atrial fibrillation and non-sustained, symptomatic episodes of ventricular tachycardia. Endomyocardial biopsy revealed lymphocytic myocarditis. She was managed with azathioprine and prednisone, as well as sotalol and apixaban for her atrial fibrillation, and has had no complications in the 12 months since discharge.", + "summary_subclaims": [ + "The patient is a 26-year-old lady.", + "She was admitted to hospital following routine echocardiography.", + "The echocardiography was requested for screening of pulmonary hypertension.", + "The echocardiogram demonstrated severe right ventricular dilatation.", + "The echocardiogram showed right ventricular impairment.", + "She was experiencing atrial fibrillation.", + "She had non-sustained, symptomatic episodes of ventricular tachycardia.", + "Endomyocardial biopsy revealed lymphocytic myocarditis.", + "She was managed with azathioprine.", + "She was managed with prednisone.", + "She was managed with sotalol.", + "She was managed with apixaban for her atrial fibrillation.", + "She has had no complications in the 12 months since discharge." + ] + }, + { + "id": "multiclinsum_test_2986_en.txt", + "fulltext": "We report the case of a 46- year-old woman with falsely elevated FT4. She had no family history of thyroid disease and suffered from hypertension and dyslipidaemia. She was an active smoker and was having peri-menopausal symptoms. No other relevant medical conditions were present. She was first presented with a serum thyrotropin (TSH) level of 20.95 µUI/mL (0.5 - 5) and a serum free thyroxin (FT4) level of 7.7 pg/mL (8 - 18). The analysis was performed on Siemens Healthcare Reagents Kit in Advia centaur platform. Thyroid peroxidase and thyroglobulin auto-antibodies levels were positive; a thyroid ultrasound showed no goiter. The patient was diagnosed with clinical autoimmune hypothyroidism and was treated with 75 micrograms of levothyroxine daily. She was discharged from the endocrinologist to her primary care physician. Annual thyroid function tests were carried out and the results were within normal range, so the dose of levothyroxine remained unchanged.\nEight years after she was first diagnosed with hypothyroidism, she showed a FT4 level of 51.7 pg/mL (8 - 18), a free triiodothyronine (FT3) level of 2.8 pg/mL (2.3 - 4.2) and a TSH level of 7.393 µUI/mL (0.5 - 5) in one of the annual routine thyroid tests performed by her primary care physician. The results were confirmed by a repeated test three weeks later. On the basis of these results, her primary care physician recommended a reduction in the dose of levothyroxine from 75 micrograms to 50 micrograms and referred the patient to the endocrinologist for further assessment. On examination, the patient had a body mass index of 35 kg/m2, no palpable goiter, a blood pressure of 129/88 mmHg and a heart rate of 98 bpm. She had recently increased her weight, to the extent of 7 kilograms in 6 month and she did not indicate tremor, palpitations, sweating, insomnia, diarrhoea or any other features of hyperthyroidism, in spite of the very high FT4 levels. She also denied having headaches or visual field problems that could have been caused by a TSH-producing pituitary adenoma. The test results in the past and the absence of family history of thyroid problems made the diagnosis of thyroid hormone resistance unlikely. Furthermore, the normal level of FT3 in the presence of high levels of FT4 pointed to the possibility of interference in the FT4 quantification.\nWith the suspicion of interference in the FT4 quantification, the laboratory chemist was contacted and a second FT4 test, in a specimen collected 20 days after the previous one, was analyzed in parallel in two different platforms. Blood specimens were collected from the patient between 8 - 10 hours AM after overnight fasting and 24 hours after the last dose of levothyroxine. Sera of patient were left at room temperature 20 minutes, followed by centrifugation at 3000g for 15 minutes. The sera were then analyzed or immediately stored at -70°C for seven days. First, an Advia centaur platform with a Siemens Healthcare Reagents Kit (Method 1) was used with quality control material freeze-dried and human based “Immunoassay Plus Control” from Biorad and a within-run CV < 5% and inter-run CV < 8%. Second an alternative immunoassay platform Cobas e 411 with Roche Diagnostics Corporation (Indianapolis) Reagent kit (Method 2) was used with quality control material human based and freeze-dried Precinorm U from Roche Corporation and an intra-assay CV < 8.11% and an inter-assay CV < 11.2%. The TSH coefficient of variation intra-assay and inter-assay in Advia Centaur Platform were < 2.8% and < 4.28%, respectively. Both Roche Cobas “e” and Advia Centaur are competitive one-step immunoassay for FT4 quantification but differ in reagents labeling. In Advia Centaur, the labeling is an analogue of T4 hormone, labelled with acrydinium-ester, which compete with the patient’s FT4 for a little quantity of polyclonal rabbit antibody bound to a solid phase. However, in Roche, the labeling is a polyclonal sheep antibody (immunometric one-step assay) labelled with sulfonyl-Rhutenium; the solid phase bound T4 analogue and the patient’s FT4 patient hormone compete for a little quantity of polyclonal sheep antibody labeled with suffonyl-Rhutenium. The results obtained by both methods are shown in . After confirming an under-treated hypothyroidism, the dose of levothyroxine was increased to the initial of 75 micrograms.\nAutoantibodies anti-T4 presence was confirmed using PEG precipitation and dilution methods, following an in house protocol based in the radioactivity measurement of the precipitant after addition of Polyethylene glycol solution 20% w/v in water to the serum patient and serum negative control previously incubated with I-125 radiolabeled -Thyroxine in the same run. Serum patient was found to be positive with a percentage of 77.4% of fixation (positive if higher than 10%). Control negative serum showed a percentage of 5% of fixation. Auto-antibodies anti-T3 were negative following the same in house protocol. The patient sample was PEG-precipitated in order to confirm the autoantibodies anti-T4 interference in FT4 Advia Centaur assay with a validated in-house protocol in an Advia centaur platform. We selected a patient control specimen with a very low FT4 concentration like Blank and another patient control specimen with very high FT4 concentration. To compare both, the matrix effect by PEG in Advia centaur acrydinium-ester label and the behaviour of a sample in the same patient range after PEG precipitation. The antibody interference gave a very discordant result before and after PEG precipitation in the patient’s problem specimen. No relevant disagreement was found in the control specimens before and after PEG precipitation.\nTo further evaluate the antibody interference, we performed a double-dilution test in order to confirm the T4-autoantibodies interference in the Advia centaur platform. We did this by using a very low FT4 level pool from hypothyroid patients as a zero diluent and patient´s control specimens without FT4 test interference as well as a very high FT4 level. All of them were analyzed at the same run. The patient sample showed a non-linear increase in the FT4 level due to the decreasing title of high avidity interfering T4-autoantibodies after double-dilution test . Finally, total T4 and T3 levels were also analyzed in Advia centaur platform in order to detect interference in total thyroid hormones. No relevant discordance was detected after the total T4 and total T3 quantification in Advia centaur platform respect the FT4 and FT3 hormones in the same platform and patient’ specimen. The total T4 level was 67.9 µg/dL (4.5 - 10.9) and the total T3 was 1.43 ng/mL (0.6 - 1.81). PEG precipitation and dilution tests were performed . Patient specimen showed a very low PEG precipitated recovery, which accounted for the PEG eliminated interference probably owing to the antiT4-autoantibodies. We speculate that the high title and high avidity patient index anti T4 autoantibodies were quenching the T4 coated paramagnetic solid phase beads, displacing the low title monoclonal mouse anti T4 from the binding site in the T4 molecule. After washing the monoclonal acrydinium labeled mouse, antiT4-antibodies were discarded and no signal was detected in the competitive assay, which explained the high Total T4 concentration observed in the patient sample in the Advia centaur platform total T4 assay.", + "fulltext_subclaims": [ + "The patient was a 46-year-old woman.", + "She had no family history of thyroid disease.", + "She had hypertension.", + "She had dyslipidaemia.", + "She was an active smoker.", + "She was having peri-menopausal symptoms.", + "She had no other relevant medical conditions.", + "She had a serum thyrotropin (TSH) level of 20.95 µUI/mL.", + "The TSH reference range was 0.5 - 5 µUI/mL.", + "She had a serum free thyroxin (FT4) level of 7.7 pg/mL.", + "The FT4 reference range was 8 - 18 pg/mL.", + "The analysis was performed on Siemens Healthcare Reagents Kit in Advia centaur platform.", + "Thyroid peroxidase and thyroglobulin auto-antibodies levels were positive.", + "A thyroid ultrasound showed no goiter.", + "The patient was diagnosed with clinical autoimmune hypothyroidism.", + "She was treated with 75 micrograms of levothyroxine daily.", + "She was discharged from the endocrinologist to her primary care physician.", + "Annual thyroid function tests were carried out.", + "The results were within normal range.", + "The dose of levothyroxine remained unchanged.", + "Eight years after diagnosis, she showed a FT4 level of 51.7 pg/mL.", + "The FT4 reference range was 8 - 18 pg/mL.", + "She had a TSH level of 7.393 µUI/mL.", + "The TSH reference range was 0.5 - 5 µUI/mL.", + "The results were confirmed by a repeated test three weeks later.", + "Her primary care physician recommended a reduction in the dose of levothyroxine from 75 micrograms to 50 micrograms.", + "The patient had a body mass index of 35 kg/m2.", + "She had recently increased her weight by 7 kilograms in 6 months.", + "She did not indicate tremor, palpitations, sweating, insomnia, diarrhoea, or any other features of hyperthyroidism.", + "She denied having headaches or visual field problems that could have been caused by a TSH-producing pituitary adenoma.", + "The test results in the past and the absence of family history of thyroid problems made the diagnosis of thyroid hormone resistance unlikely.", + "The normal level of FT3 in the presence of high levels of FT4 pointed to the possibility of interference in the FT4 quantification.", + "With the suspicion of interference in the FT4 quantification, the laboratory chemist was contacted.", + "A second FT4 test was analyzed in parallel in two different platforms.", + "Blood specimens were collected from the patient between 8 - 10 hours AM after overnight fasting.", + "Blood specimens were collected 24 hours after the last dose of levothyroxine.", + "Sera were left at room temperature 20 minutes, followed by centrifugation at 3000g for 15 minutes.", + "The sera were then analyzed or immediately stored at -70°C for seven days.", + "An Advia centaur platform with a Siemens Healthcare Reagents Kit was used.", + "A Cobas e 411 with Roche Diagnostics Corporation Reagent kit was used.", + "Both Roche Cobas “e” and Advia Centaur are competitive one-step immunoassay for FT4 quantification.", + "The labeling in Advia Centaur is an analogue of T4 hormone, labelled with acrydinium-ester.", + "The labeling in Roche is a polyclonal sheep antibody labelled with sulfonyl-Rhutenium.", + "Autoantibodies anti-T4 presence was confirmed using PEG precipitation and dilution methods.", + "The patient sample was found to be positive with a percentage of 77.4% of fixation.", + "Control negative serum showed a percentage of 5% of fixation.", + "Auto-antibodies anti-T3 were negative following the same in house protocol.", + "The patient sample was PEG-precipitated to confirm the autoantibodies anti-T4 interference in FT4 Advia Centaur assay.", + "The antibody interference gave a very discordant result before and after PEG precipitation in the patient’s problem specimen.", + "No relevant disagreement was found in the control specimens before and after PEG precipitation.", + "A double-dilution test was performed to confirm the T4-autoantibodies interference in the Advia centaur platform.", + "The patient sample showed a non-linear increase in the FT4 level due to the decreasing title of high avidity interfering T4-autoantibodies after double-dilution test.", + "Total T4 and T3 levels were also analyzed in Advia centaur platform.", + "No relevant discordance was detected after the total T4 and total T3 quantification.", + "The total T4 level was 67.9 µg/dL.", + "The total T3 was 1.43 ng/mL.", + "PEG precipitation and dilution tests were performed.", + "Patient specimen showed a very low PEG precipitated recovery.", + "We speculate that the high title and high avidity patient index anti T4 autoantibodies were quenching the T4 coated paramagnetic solid phase beads.", + "The monoclonal acrydinium labeled mouse antiT4-antibodies were discarded and no signal was detected in the competitive assay.", + "This explained the high Total T4 concentration observed in the patient sample in the Advia centaur platform total T4 assay." + ], + "summary": "We report the case of a 46- year-old female patient with autoimmune hypothyroidism in chronic replacement treatment with levothyroxine who was presented 8 years after diagnosis with a thyroid function test showing an increased level of TSH and a very high level of FT4. Interference in the laboratory serum free thyroxin (FT4) test was suspected, due to the lack of symptoms of hyperthyroidism and a different immunoassay platform confirmed a low FT4 result. The discrepancy between the two results was explained by the presence of antiT4-autoantibodies.", + "summary_subclaims": [ + "The patient is a 46-year-old female.", + "The patient has autoimmune hypothyroidism.", + "The patient was in chronic replacement treatment with levothyroxine.", + "The patient was presented 8 years after diagnosis.", + "The thyroid function test showed an increased level of TSH.", + "The thyroid function test showed a very high level of FT4.", + "Interference in the laboratory serum free thyroxin (FT4) test was suspected.", + "The patient had no symptoms of hyperthyroidism.", + "A different immunoassay platform confirmed a low FT4 result.", + "The discrepancy between the two results was explained by the presence of antiT4-autoantibodies." + ] + }, + { + "id": "multiclinsum_test_2410_en.txt", + "fulltext": "A 49-year-old male was referred to our emergency department complaining of progressive aggravated abdominal pain for 3 d.\nThe initial pain was in the hypogastric region and worsened to diffuse abdominal pain 1 d prior, along with nausea, abdominal distension, and vomiting.\nThe patient had suffered from hypertension for 10 years, which was well controlled medically by nifedipine and metoprolol. His past surgical history of renal transplantation had been 4 years due to chronic kidney disease. The immunosuppression therapy included prednisolone, mycophenolate mofetil, and tacrolimus.\nThe patient had a free personal and family history.\nClinical examination revealed tenderness on palpation of his full abdomen with rebound tenderness and muscle guarding.\nLaboratory evaluation showed that the leucocytes count was elevated at 31 × 109/mL, hemoglobin was 13 g/dL, and C-reactive protein was 33.86 mg/dL. The hepatitis serology and cytomegalovirus results did not suggest clinical virus infection.\nThe abdominal contrast-enhanced computed tomography (CT) scan exhibited an extensive filling defect within the portal vein and right branch, extending to the superior mesenteric vein as well as splenic vein .", + "fulltext_subclaims": [ + "A 49-year-old male was referred to our emergency department complaining of progressive aggravated abdominal pain for 3 d.", + "The initial pain was in the hypogastric region.", + "The pain worsened to diffuse abdominal pain 1 d prior.", + "The patient had nausea.", + "The patient had abdominal distension.", + "The patient had vomiting.", + "The patient had suffered from hypertension for 10 years.", + "The patient's hypertension was well controlled medically by nifedipine and metoprolol.", + "The patient had a past surgical history of renal transplantation.", + "The renal transplantation had been 4 years due to chronic kidney disease.", + "The immunosuppression therapy included prednisolone, mycophenolate mofetil, and tacrolimus.", + "The patient had a free personal and family history.", + "Clinical examination revealed tenderness on palpation of his full abdomen.", + "Rebound tenderness was present.", + "Muscle guarding was present.", + "The leucocytes count was elevated at 31 × 109/mL.", + "Hemoglobin was 13 g/dL.", + "C-reactive protein was 33.86 mg/dL.", + "The hepatitis serology and cytomegalovirus results did not suggest clinical virus infection.", + "The abdominal contrast-enhanced computed tomography (CT) scan exhibited an extensive filling defect within the portal vein and right branch.", + "The filling defect extended to the superior mesenteric vein.", + "The filling defect extended to the splenic vein." + ], + "summary": "Here we present a rare case of acute MVT developed 3 years after renal transplantation. A 49-year-old patient was admitted with acute abdominal pain and diagnosed as MVT with intestinal necrosis. An emergency exploratory laparotomy was performed to remove the infarcted segment of the bowel. Immediate systemic anticoagulation was also initiated. During the treatment, the patient experienced bleeding, anastomotic leakage, and sepsis. However, after aggressive treatment was administered, all thrombi were completely resolved, and the patient recovered with his renal graft function unimpaired.", + "summary_subclaims": [ + "This is a rare case of acute mesenteric venous thrombosis (MVT) developed 3 years after renal transplantation.", + "The patient was a 49-year-old individual.", + "The patient was admitted with acute abdominal pain.", + "The patient was diagnosed as MVT with intestinal necrosis.", + "An emergency exploratory laparotomy was performed.", + "The infarcted segment of the bowel was removed.", + "Immediate systemic anticoagulation was initiated.", + "The patient experienced bleeding.", + "The patient experienced anastomotic leakage.", + "The patient experienced sepsis.", + "After aggressive treatment was administered, all thrombi were completely resolved.", + "The patient recovered.", + "The patient's renal graft function was unimpaired." + ] + }, + { + "id": "multiclinsum_test_732_en.txt", + "fulltext": "A 64-year-old male was brought to the emergency department (ED) by helicopter after sustaining an injury falling over a fence. The patient reported injuring his “stomach” and feeling a pop followed by severe back pain. On scene, the prehospital paramedics reported no pulses in the bilateral lower extremities. Prior to arrival, the patient had been given 250 micrograms fentanyl, 20 milligrams (mg) labetalol, and 4 mg of midazolam by medics for concern of possible aortic dissection. Vital signs upon arrival included a blood pressure of 166/102 millimeters of mercury, heart rate of 92 beats per minute, 16 respirations per minute, an oxygen saturation of 96% on room air, and a temperature of 99.2ºF. Physical examination was notable for 2+ carotid and radial pulses bilaterally, and absent dorsalis pedis and popliteal pulses bilaterally. Point-of-care ultrasound identified a large infrarenal abdominal aortic aneurysm (AAA) of approximately 7 centimeters (cm) in size with contained thrombus within the lumen. ( and ).\nComputed tomography angiography of the chest, abdomen, and pelvis reaffirmed the presence of an acutely ulcerated thrombus contained within the lumen of the aorta and no evidence of extraluminal contrast extravasation. This information, combined with vascular duplex ultrasound of the lower extremity confirming extensive clot burden down to the level of the dorsalis pedis, was presented to our vascular surgeon and therapeutic interventional radiologist on call. In shared decision-making with the patient, this multidisciplinary team initiated anticoagulation with unfractionated heparin and transferred the patient to the operating room for emergent embolectomy and intra-arterial tissue plasminogen activator.", + "fulltext_subclaims": [ + "The patient was a 64-year-old male.", + "The patient was brought to the emergency department by helicopter.", + "The patient reported injuring his 'stomach' and feeling a pop followed by severe back pain.", + "On scene, the prehospital paramedics reported no pulses in the bilateral lower extremities.", + "Prior to arrival, the patient had been given 250 micrograms fentanyl.", + "Prior to arrival, the patient had been given 20 milligrams labetalol.", + "Prior to arrival, the patient had been given 4 mg of midazolam.", + "Vital signs upon arrival included a blood pressure of 166/102 millimeters of mercury.", + "Vital signs upon arrival included a heart rate of 92 beats per minute.", + "Vital signs upon arrival included 16 respirations per minute.", + "Vital signs upon arrival included an oxygen saturation of 96% on room air.", + "Vital signs upon arrival included a temperature of 99.2ºF.", + "Physical examination was notable for 2+ carotid and radial pulses bilaterally.", + "Physical examination was notable for absent dorsalis pedis and popliteal pulses bilaterally.", + "Point-of-care ultrasound identified a large infrarenal abdominal aortic aneurysm of approximately 7 centimeters in size.", + "Computed tomography angiography of the chest, abdomen, and pelvis reaffirmed the presence of an acutely ulcerated thrombus contained within the lumen of the aorta.", + "Computed tomography angiography showed no evidence of extraluminal contrast extravasation.", + "Vascular duplex ultrasound of the lower extremity confirmed extensive clot burden down to the level of the dorsalis pedis.", + "The patient was transferred to the operating room for emergent embolectomy.", + "The patient received intra-arterial tissue plasminogen activator." + ], + "summary": "A 64-year-old man with a history of a 5.5-centimeter (cm) abdominal aortic aneurysm (AAA) presented to the emergency department (ED) complaining of severe back pain after climbing over a fence and falling a distance of eight feet. Prior to arrival, the prehospital paramedics reported that the patient did not have palpable pulses in either lower extremity. The initial physical examination in the ED was significant for absent dorsalis pedis pulses bilaterally as well as absent posterior tibialis pulses bilaterally and cold, insensate lower extremities. Point-of-care ultrasound identified an approximate 7-cm infrarenal AAA with a mural thrombus present. After receiving several computed tomography (CT) studies including CT head without contrast and CT angiography of the chest, abdomen and pelvis, the patient was diagnosed with acute thrombosis of AAA and associated thromboembolic occlusion of both his right and left distal iliac vessels causing bilateral acute limb ischemia. He immediately received unfractionated heparin and was admitted to the hospital for embolectomy and intra-arterial tissue plasminogen activator.", + "summary_subclaims": [ + "The patient is a 64-year-old man.", + "The patient has a history of a 5.5-centimeter abdominal aortic aneurysm.", + "The patient presented to the emergency department complaining of severe back pain.", + "The patient climbed over a fence and fell a distance of eight feet.", + "Prior to arrival, the prehospital paramedics reported that the patient did not have palpable pulses in either lower extremity.", + "The initial physical examination in the ED was significant for absent dorsalis pedis pulses bilaterally.", + "The initial physical examination in the ED was significant for absent posterior tibialis pulses bilaterally.", + "The initial physical examination in the ED was significant for cold, insensate lower extremities.", + "Point-of-care ultrasound identified an approximate 7-cm infrarenal abdominal aortic aneurysm.", + "Point-of-care ultrasound identified a mural thrombus.", + "The patient was diagnosed with acute thrombosis of abdominal aortic aneurysm.", + "The patient was diagnosed with thromboembolic occlusion of both right and left distal iliac vessels.", + "The patient was diagnosed with bilateral acute limb ischemia.", + "The patient immediately received unfractionated heparin.", + "The patient was admitted to the hospital for embolectomy.", + "The patient was admitted to the hospital for intra-arterial tissue plasminogen activator." + ] + }, + { + "id": "multiclinsum_test_2320_en.txt", + "fulltext": "A 50-year-old female presented with a 2-month history of progressive left foot drop and mild tenderness over the left fibular head, with the gradual development of swelling in the area. On examination, there was a soft to firm, poorly defined swelling in the area below the fibular head. There was a weakness in foot eversion and dorsiflexion, particularly of the great toe. Foot plantar flexion and inversion were normal. The swelling was screened with an ultrasound, which showed a hypoechogenic cystic mass. Nerve conduction study showed delayed latency and decreased conduction velocity compared to the contralateral limb. An electromyogram was done which demonstrated a denervation potential the right tibialis anterior and extensor digitorum longus muscles. The patient was diagnosed with peroneal nerve palsy and was initially conservatively managed with ankle-foot orthosis for protection and expectant spontaneous recovery. The symptoms did not resolve, and subsequent magnetic resonance imaging (MRI) showed an elongated tubular, cystic-appearing mass near the fibular neck extending down till the middle third of the leg . The cyst was excised using an incision starting just posterior to fibular head. The fascia of the posterior compartment was incised, and the peroneal nerve was identified just beneath the cyst . The nerve was traced distally as well as proximally to prevent any inadvertent injury while cyst excision. The cyst was followed distally till its stalk and removed in toto . Loop magnification was used to prevent any injury to the fine branches arising from nerve along its course. The mass measured approximately 13.0 cm×2.0 cm×2.0 cm. It was then explored for its proximal extension and removed, which measured 2.0 cm×2.0 cm×2.0 cm (, , ).The peroneal nerve was inspected and found to be completely intact. The specimen was sent for histopathology which confirmed the diagnosis of a ganglion cyst . There was an immediate clinical improvement in motor function within the 1stweek. Repeat electromyography (EMG) showed long-duration polyphasic motor unit potentials in tibialis anterior and extensor digitorum and clinical recovery of foot drop. At 6-month follow-up, the patient reported full clinical recovery , there were no signs of recurrence on ultrasonography (USG) even at 24-month follow-up.", + "fulltext_subclaims": [ + "The patient is a 50-year-old female.", + "She had a 2-month history of progressive left foot drop.", + "She had mild tenderness over the left fibular head.", + "There was a gradual development of swelling in the area.", + "On examination, there was a soft to firm, poorly defined swelling in the area below the fibular head.", + "There was weakness in foot eversion and dorsiflexion, particularly of the great toe.", + "Foot plantar flexion and inversion were normal.", + "An ultrasound showed a hypoechogenic cystic mass.", + "Nerve conduction study showed delayed latency and decreased conduction velocity compared to the contralateral limb.", + "An electromyogram demonstrated a denervation potential in the right tibialis anterior and extensor digitorum longus muscles.", + "The patient was diagnosed with peroneal nerve palsy.", + "She was initially conservatively managed with an ankle-foot orthosis.", + "The symptoms did not resolve.", + "Subsequent MRI showed an elongated tubular, cystic-appearing mass near the fibular neck extending down till the middle third of the leg.", + "The cyst was excised using an incision starting just posterior to the fibular head.", + "The fascia of the posterior compartment was incised.", + "The peroneal nerve was identified just beneath the cyst.", + "The nerve was traced distally as well as proximally to prevent any inadvertent injury while cyst excision.", + "The cyst was followed distally till its stalk and removed in toto.", + "Loop magnification was used to prevent any injury to the fine branches arising from the nerve along its course.", + "The mass measured approximately 13.0 cm×2.0 cm×2.0 cm.", + "The proximal extension of the mass measured 2.0 cm×2.0 cm×2.0 cm.", + "The peroneal nerve was found to be completely intact.", + "The specimen was sent for histopathology.", + "Histopathology confirmed the diagnosis of a ganglion cyst.", + "There was an immediate clinical improvement in motor function within the 1st week.", + "Repeat electromyography showed long-duration polyphasic motor unit potentials in tibialis anterior and extensor digitorum.", + "Clinical recovery of foot drop was noted.", + "At 6-month follow-up, the patient reported full clinical recovery.", + "There were no signs of recurrence on ultrasonography at 24-month follow-up." + ], + "summary": "A 50-year-old female presented with a 2-month history of progressive left foot drop with a gradual development of swelling over the left fibular head. Imaging suggested ganglion cyst-induced peroneal nerve palsy. Initial conservative treatment failure warranted surgical excision which confirmed extraneural origin on histopathological examination. An immediate clinical improvement was observed postoperatively and full recovery occurred within 6 months. There was no recurrence at 2 years follow up.", + "summary_subclaims": [ + "The patient is a 50-year-old female.", + "She had a 2-month history of progressive left foot drop.", + "She had a gradual development of swelling over the left fibular head.", + "Imaging suggested ganglion cyst-induced peroneal nerve palsy.", + "Initial conservative treatment failed.", + "Surgical excision was performed.", + "Histopathological examination confirmed extraneural origin.", + "An immediate clinical improvement was observed postoperatively.", + "Full recovery occurred within 6 months.", + "There was no recurrence at 2 years follow up." + ] + }, + { + "id": "multiclinsum_test_1765_en.txt", + "fulltext": "An 11-year-old skeletally immature girl presented to us 2 years back with pain and swelling over the right forearm without any restriction of moments and other constitutional symptoms. The patient had a similar problem 4 years back , for which she underwent surgery elsewhere and she completely recovered. Available biopsy reports suggested a non-ossifying fibroma. On examination, the patient had a tender bony thickening of radius extending to about 2cm underneath the previous surgical scar which was a 5cm anterolateral longitudinal surgical scar in the region of the middle third and distal third junction of forearm. The patient had no neurovascular deficit.\nX-ray radiography showed a 1cm diameter multiloculated lesion involving the complete diameter of bone with sclerotic rim in the distal diaphysis of radius, with no periosteal reaction and cortical breach . Magnetic resonance (MR) imaging showed a well-defined expansile lytic, trabeculated lesion with multiple internal septations region ( and ). Since the previous biopsy report from a reputed institute suggested non-ossifying fibroma 4 years back, we did not go for further studies like bone scan. As the lesion was painful and the child had difficulty in carrying heavy objects, we decided to intervene. Based on the previous biopsy report and imaging features, we decided to perform direct intralesional excision (curettage) of the lesion. Radius was exposed through the previous surgical scar (Henry’s approach) without tourniquet control. During exposure, we found gross adhesions around radial artery due to the previous exposure. Radial artery was accidentally cut, repair was not attempted and hence ligated. Under image intensifier guidance, the lesion was identified and bone window was made. Tumor tissue was thoroughly curetted and the defect was filled with artificial bone substitute (STIMULAN calcium sulfate beads).\nTumor tissue was sent for biopsy. Above elbow, POP slab was applied for 6 weeks. Histopathology showed tissue with spindle cells arranged in fascicles and bundles in a storiform pattern along with osteoclast such as giant cells and no evidence of cytological atypia/atypical mitosis/necrosis suggestive of non-ossifying fibroma . The patient was put on the above elbow POP slab for 2 weeks and converted to POP cast for the next 4 weeks. At 6 weeks, POP was removed and an active range of motion exercises of wrist started. The patient was advised not to involve in sports activities for nearly 6months until bony union was seen radiologically. The patient was serially followed up. Post-operative radiograph showed some residual tumor involving the dorsal cortex which was noted even at 1-year follow-up X-ray .The patient was followed up for 3 years. Tumor was completely regressed and was not seen on X-ray . She had a full range of movement with no functional deformity (-).", + "fulltext_subclaims": [ + "The patient is an 11-year-old skeletally immature girl.", + "She presented 2 years back with pain and swelling over the right forearm.", + "There was no restriction of moments.", + "There were no other constitutional symptoms.", + "The patient had a similar problem 4 years back.", + "She underwent surgery elsewhere for the previous problem.", + "She completely recovered from the previous surgery.", + "Available biopsy reports suggested a non-ossifying fibroma.", + "On examination, the patient had a tender bony thickening of radius.", + "The bony thickening extended to about 2cm underneath the previous surgical scar.", + "The previous surgical scar was a 5cm anterolateral longitudinal scar.", + "The scar was located at the middle third and distal third junction of the forearm.", + "The patient had no neurovascular deficit.", + "X-ray radiography showed a 1cm diameter multiloculated lesion.", + "The lesion involved the complete diameter of bone.", + "The lesion had a sclerotic rim in the distal diaphysis of radius.", + "There was no periosteal reaction.", + "There was no cortical breach.", + "Magnetic resonance imaging showed a well-defined expansile lytic, trabeculated lesion.", + "The lesion had multiple internal septations.", + "The previous biopsy report from a reputed institute suggested non-ossifying fibroma 4 years back.", + "We did not go for further studies like bone scan.", + "The lesion was painful.", + "The child had difficulty in carrying heavy objects.", + "We decided to intervene.", + "We decided to perform direct intralesional excision (curettage) of the lesion.", + "Radius was exposed through the previous surgical scar.", + "The surgical approach was Henry’s approach.", + "There was no tourniquet control.", + "During exposure, we found gross adhesions around radial artery.", + "Radial artery was accidentally cut.", + "Repair was not attempted.", + "Radial artery was ligated.", + "Under image intensifier guidance, the lesion was identified.", + "A bone window was made.", + "Tumor tissue was thoroughly curetted.", + "The defect was filled with artificial bone substitute.", + "The artificial bone substitute used was STIMULAN calcium sulfate beads.", + "Tumor tissue was sent for biopsy.", + "A POP slab was applied for 6 weeks.", + "Histopathology showed tissue with spindle cells arranged in fascicles and bundles in a storiform pattern.", + "The histopathology showed osteoclast-like giant cells.", + "There was no evidence of cytological atypia.", + "There was no evidence of atypical mitosis.", + "There was no evidence of necrosis.", + "The histopathology was suggestive of non-ossifying fibroma.", + "The patient was put on the above elbow POP slab for 2 weeks.", + "The patient was then converted to a POP cast for the next 4 weeks.", + "At 6 weeks, POP was removed.", + "Active range of motion exercises of wrist were started.", + "The patient was advised not to involve in sports activities for nearly 6 months.", + "The patient was serially followed up.", + "Post-operative radiograph showed some residual tumor involving the dorsal cortex.", + "The residual tumor was noted even at 1-year follow-up X-ray.", + "The patient was followed up for 3 years.", + "The tumor was completely regressed and was not seen on X-ray.", + "She had a full range of movement.", + "There was no functional deformity." + ], + "summary": "An 11-year-old skeletally immature girl presented to us two 2 years back with pain and swelling over the right forearm without any restriction of moments and other constitutional symptoms. She was diagnosed to have non-ossifying fibroma and had underwent surgery for the same 4years back. Radiographic and higher imaging studies suggested non-ossifying fibroma. Since the lesion was painful and the child had difficulty in carrying heavy objects, we decided to intervene. Tumour tissue was thoroughly curetted and the defect was filled with artificial bone substitute. Biopsy confirmed the diagnosis of non-ossifying fibroma and post-operative radiograph showed some residual tumour which was noted even at one 1-year follow-up X-ray. On 3-years follow-up,the patient was symptom-free with no residual lesion and complete incorporation of the artificial bone substitute.", + "summary_subclaims": [ + "The patient is an 11-year-old skeletally immature girl.", + "She presented two years back with pain and swelling over the right forearm.", + "There was no restriction of moments.", + "There were no other constitutional symptoms.", + "She was diagnosed to have non-ossifying fibroma.", + "She had undergone surgery for the same four years back.", + "Radiographic and higher imaging studies suggested non-ossifying fibroma.", + "The lesion was painful.", + "The child had difficulty in carrying heavy objects.", + "Tumour tissue was thoroughly curetted.", + "The defect was filled with artificial bone substitute.", + "Biopsy confirmed the diagnosis of non-ossifying fibroma.", + "Post-operative radiograph showed some residual tumour.", + "Residual tumour was noted even at one-year follow-up X-ray.", + "On three-year follow-up, the patient was symptom-free.", + "There was no residual lesion on three-year follow-up.", + "The artificial bone substitute was completely incorporated." + ] + }, + { + "id": "multiclinsum_test_1294_en.txt", + "fulltext": "On March 14, 2022, a 7-year-old girl was admitted to Wuhan Children's Hospital, Tongji Medical College, Huazhong University of Science and Technology due to noticeable behavioral changes occurring over the past months. These changes included episodes of eye rolling, mouth twitching, and pronounced mouth breathing, lasting approximately 3-5 minutes, particularly when fatigued, happening about 4-5 times per day. Shortly after these episodes, the child would suddenly rise and move about in a seated position, engaging in self-talk and hand-and-foot movements for several hours. The child had been diagnosed with epilepsy at the age of 1, effectively managed with oral levetiracetam. In March 2021, the patient developed intermittent fever and a decrease in blood cell counts. After a thorough examination, the patient was diagnosed with Shwachman-Diamond syndrome (SDS), a genetic condition marked by bone marrow failure and an elevated risk of hematological malignancies. Using whole-exome sequencing, we identified a homozygous splice site variant and this c.258 + 2T>C variant at the 5’ splice site (ss) is associated with aberrant pre-mRNA splicing due to the usage of an upstream cryptic 5’ss at positions c.251-252, eventually resulting in an 8-bp deletion and frameshift (84Cfs3) . In November 2021, the patient underwent HSCT from an unrelated HLA9/10-compatible donor at the Department of Pediatrics, Union Hospital Affiliated to Tongji Medical College, Huazhong University of Science and Technology. There were no signs of acute or chronic graft-versus-host disease after HSCT. There was no significant personal history of trauma, infections, tuberculosis exposure, toxin exposure, allergies, or familial metabolic diseases. Upon admission, the patient exhibited stable vital signs, appropriate responsiveness, and normal brain function. Physical examinations revealed a supple neck with non-palpable superficial lymph nodes. Assessments of the heart, lungs, abdomen, and limb muscle strength were normal. Kernig’s and Brudzinski signs were negative, and the heel-knee-shin test showed stability. Imaging tests, including diffusion-weighted magnetic resonance imaging (MRI) of the head, computed tomography scans of the chest, abdomen, and pelvis, superficial lymph node ultrasound, and positron emission tomography-computed tomography, showed no significant abnormalities. The EEG indicated a dominant rhythm without prominence, increased slow wave activity during wakefulness, and occasional paroxysmal multi-spike slow waves during sleep . Integrated sensory and cognitive assessments reported mild proprioceptive and body coordination issues. The self-rating anxiety scale, self-rating depression scale, children’s psychological counseling test report, and China-Wechsler children’s intelligence scale all exhibited normal results. Laboratory tests, including blood counts, blood coagulation, urine and stool routines, liver and kidney function, thyroid function, C-reactive protein, procalcitonin, electrolyte levels, myocardial enzymes, blood ammonia, lactic acid, blood glucose, anti-nuclear antibodies, and anti-extractable nuclear antigen antibodies, all returned within normal ranges. Lymphocyte subsets detection displayed abnormalities . The patient tested positive for Epstein-Barr virus core antigen, Epstein-Barr virus capsid antigen, cytomegalovirus antibodies, and herpes simplex virus I and II immunoglobulin G (IgG). However, fungal glucan, galactomannan tests, pre-transfusion infectious disease screening, tuberculosis microarray, and parvovirus B-19 yielded negative results. Routine cerebrospinal fluid biochemistry, exfoliative cytology, bacterial cultures, and smears (for common bacteria, cryptococci, and fungi) were all unremarkable. Moreover, 12 cerebrospinal fluid AE antibodies, along with oligoclonal bands and myelin basic protein, tested negative . Bone marrow cytology and immunophenotypes were generally normal. Double immunofluorescence cell staining revealed elevated anti-mGluR5 antibody levels in the serum (1:1000) . A final diagnosis of anti-mGluR5 AE was established. The patient received treatment with intravenous gamma globulin (400 mg/kg daily for 5 consecutive days) and methylprednisolone (20 mg/kg daily for 5 consecutive days), followed by oral prednisone. During hormonal shock therapy, omeprazole was administered for gastric protection, along with calcium and potassium supplementation. Levetiracetam and trihexyphenidyl were concurrently prescribed for epilepsy and dystonia, respectively. The abnormal behaviors notably improved after treatment, and EEG results improved . A re-examination in January 2023 revealed the absence of an SBDS gene mutation in peripheral blood. The patient remained symptom-free at the last follow-up in August 2023.", + "fulltext_subclaims": [ + "A 7-year-old girl was admitted to Wuhan Children's Hospital on March 14, 2022.", + "The girl had episodes of eye rolling, mouth twitching, and mouth breathing lasting 3-5 minutes.", + "The episodes occurred about 4-5 times per day, particularly when fatigued.", + "After the episodes, the girl would suddenly rise and move about in a seated position.", + "She engaged in self-talk and hand-and-foot movements for several hours.", + "The child had been diagnosed with epilepsy at the age of 1.", + "The epilepsy was effectively managed with oral levetiracetam.", + "In March 2021, the patient developed intermittent fever and a decrease in blood cell counts.", + "The patient was diagnosed with Shwachman-Diamond syndrome (SDS).", + "Whole-exome sequencing identified a homozygous splice site variant.", + "The c.258 + 2T>C variant is associated with aberrant pre-mRNA splicing.", + "The variant results in an 8-bp deletion and frameshift (84Cfs3).", + "In November 2021, the patient underwent HSCT from an unrelated HLA9/10-compatible donor.", + "There were no signs of acute or chronic graft-versus-host disease after HSCT.", + "The patient had no significant personal history of trauma, infections, tuberculosis exposure, toxin exposure, allergies, or familial metabolic diseases.", + "Upon admission, the patient exhibited stable vital signs, appropriate responsiveness, and normal brain function.", + "Physical examinations revealed a supple neck with non-palpable superficial lymph nodes.", + "Imaging tests, including diffusion-weighted MRI of the head, showed no significant abnormalities.", + "The EEG indicated a dominant rhythm without prominence.", + "The EEG showed increased slow wave activity during wakefulness.", + "The EEG showed occasional paroxysmal multi-spike slow waves during sleep.", + "Integrated sensory and cognitive assessments reported mild proprioceptive and body coordination issues.", + "The self-rating anxiety scale, self-rating depression scale, children’s psychological counseling test report, and China-Wechsler children’s intelligence scale all exhibited normal results.", + "Laboratory tests, including blood counts, blood coagulation, urine and stool routines, liver and kidney function, thyroid function, C-reactive protein, procalcitonin, electrolyte levels, myocardial enzymes, blood ammonia, lactic acid, blood glucose, anti-nuclear antibodies, and anti-extractable nuclear antigen antibodies, all returned within normal ranges.", + "Lymphocyte subsets detection displayed abnormalities.", + "The patient tested positive for Epstein-Barr virus core antigen.", + "The patient tested positive for Epstein-Barr virus capsid antigen.", + "The patient tested positive for cytomegalovirus antibodies.", + "The patient tested positive for herpes simplex virus I and II immunoglobulin G.", + "Fungal glucan, galactomannan tests, pre-transfusion infectious disease screening, tuberculosis microarray, and parvovirus B-19 yielded negative results.", + "Routine cerebrospinal fluid biochemistry, exfoliative cytology, bacterial cultures, and smears were all unremarkable.", + "Twelve cerebrospinal fluid AE antibodies, along with oligoclonal bands and myelin basic protein, tested negative.", + "Bone marrow cytology and immunophenotypes were generally normal.", + "Double immunofluorescence cell staining revealed elevated anti-mGluR5 antibody levels in the serum (1:1000).", + "A final diagnosis of anti-mGluR5 AE was established.", + "The patient received intravenous gamma globulin (400 mg/kg daily for 5 consecutive days).", + "The patient received methylprednisolone (20 mg/kg daily for 5 consecutive days).", + "The patient was followed with oral prednisone.", + "During hormonal shock therapy, omeprazole was administered for gastric protection.", + "Calcium and potassium supplementation were provided.", + "Levetiracetam and trihexyphenidyl were concurrently prescribed.", + "The abnormal behaviors notably improved after treatment.", + "EEG results improved after treatment.", + "A re-examination in January 2023 revealed the absence of an SBDS gene mutation in peripheral blood.", + "The patient remained symptom-free at the last follow-up in August 2023." + ], + "summary": "In this instance, we present the case of a 7-year-old girl who exhibited abnormal behaviors following hematopoietic stem cell transplantation (HSCT). She received a diagnosis of anti-mGluR5 AE, and her Electroencephalogram (EEG) displayed an increased number of generalized slow waves during wakefulness. Treatment involved intravenous administration of gamma globulin and methylprednisolone, followed by oral prednisone tablets. Levetiracetam was introduced as an antiepileptic therapy during the pulse steroid therapy. Notably, the abnormal behaviors exhibited significant improvement after treatment.", + "summary_subclaims": [ + "The patient is a 7-year-old girl.", + "She exhibited abnormal behaviors following hematopoietic stem cell transplantation.", + "She received a diagnosis of anti-mGluR5 AE.", + "Her Electroencephalogram displayed an increased number of generalized slow waves during wakefulness.", + "Treatment involved intravenous administration of gamma globulin.", + "Treatment involved intravenous administration of methylprednisolone.", + "Treatment involved oral prednisone tablets.", + "Levetiracetam was introduced as an antiepileptic therapy during the pulse steroid therapy.", + "The abnormal behaviors exhibited significant improvement after treatment." + ] + }, + { + "id": "multiclinsum_test_2419_en.txt", + "fulltext": "A 8-year-old Asian Indian male presented with complaints of pain, swelling and eruptions on right upper and lower lids for the last 7 days. No significant past medical/surgical/ family/social history was elicited. No rhinitis/pharyngitis/fever was present. No preauricular lymphadenopathy was present. Vision was 6/6 in both eyes. Vesicular eruptions were present on right side of face near the periorbital region, and right upper and lower lids showed swelling and vesicular eruption. Corneal sensations were diminished in the right eye.\nSlit lamp examination of the right eye with fluorescein staining showed well defined area of fluorescein staining in the lower bulbar conjunctiva resembling a geographic ulcer with irregular, angulated margins. Anterior segment and posterior segment examination were unremarkable. Patient was started on Acyclovir (3%) ointment 5 times/day local application on eye and skin and oral Acyclovir 200 mg 5 times/day. He was reviewed after 3 days and then after 12 days. Patient recovered completely after 12 days and medications were terminated.", + "fulltext_subclaims": [ + "The patient is an 8-year-old Asian Indian male.", + "The patient had pain, swelling, and eruptions on the right upper and lower lids for the last 7 days.", + "No significant past medical, surgical, family, or social history was elicited.", + "No rhinitis, pharyngitis, or fever was present.", + "No preauricular lymphadenopathy was present.", + "Vision was 6/6 in both eyes.", + "Vesicular eruptions were present on the right side of the face near the periorbital region.", + "The right upper and lower lids showed swelling and vesicular eruption.", + "Corneal sensations were diminished in the right eye.", + "Slit lamp examination of the right eye with fluorescein staining showed a well-defined area of fluorescein staining in the lower bulbar conjunctiva resembling a geographic ulcer with irregular, angulated margins.", + "Anterior segment and posterior segment examination were unremarkable.", + "The patient was started on Acyclovir (3%) ointment 5 times/day local application on the eye and skin.", + "The patient was started on oral Acyclovir 200 mg 5 times/day.", + "The patient was reviewed after 3 days and then after 12 days.", + "The patient recovered completely after 12 days.", + "Medications were terminated." + ], + "summary": "We report a case of primary ocular herpes with blepharitis and geographic ulceration of the conjunctiva in an 8-year-old male with no corneal lesion. To the best of our knowledge only 4 cases of conjunctival herpetic dendritic ulcerations and a single case of herpetic geographical ulcer have been reported in literature till date.", + "summary_subclaims": [ + "We report a case of primary ocular herpes with blepharitis and geographic ulceration of the conjunctiva in an 8-year-old male.", + "The patient had no corneal lesion.", + "To the best of our knowledge only 4 cases of conjunctival herpetic dendritic ulcerations have been reported in literature till date.", + "To the best of our knowledge a single case of herpetic geographical ulcer has been reported in literature till date." + ] + }, + { + "id": "multiclinsum_test_2245_en.txt", + "fulltext": "A 12-year-old Italian boy, 34 kg body weight, was referred to the PED with a 24-hour history of intermittent chest pain, cough, wheezing, and mild fever. His medications prior to arrival consisted of 0.2 mg of inhaled salbutamol every 3 hours, initiated the previous day without medical advice (overall 1.4 mg/24 hours). The last administration had been performed 1 hour before arrival. No inciting exercise was reported, and use of hypoallergenic material was reported in his bedroom. Salbutamol inhaler had been prescribed by his pneumologist as part of patient’s asthma action plan. Noteworthily, montelukast treatment was discontinued 5 days earlier on the advice of his pneumologist, after a 3-month period without asthma exacerbations.\nPast medical history included intermittent asthma induced by exercise and by dust mites diagnosed 1 year earlier. Only one mild exacerbation occurred 9 months following diagnosis, which did not require hospitalization. At that time, hypoallergenic material was not available in his bedroom.\nAt presentation, vital signs were as follows: heart rate 110 beats per minute, respiratory rate 38 breaths per minute, 94% oxygen saturation on room air, and temperature 37.1 °C.\nPhysical examination showed intercostal and substernal retractions, diffuse reductions in normal breath sound, and end-expiratory wheezing. His ability to speak was not affected. A pediatric asthma score of 9 was then calculated . Blood gas test results at presentation as well as other blood examination results and vital signs are listed in Table .\nThe patient was diagnosed with moderate asthma attack and was therefore treated with 40 mg intravenous methylprednisolone and 3.75 mg (0.11 mg/kg) nebulized salbutamol together with 0.5 mg ipratropium bromide at 20-minute intervals. Three oxygen-driven nebulizations were performed because of persistent wheezing, retractions, and moderate hypoxia (oxygen saturation between 90% and 95% on room air).\nFive minutes after the end of the third nebulization, a presyncope episode occurred. At onset, vital signs were normal, apart from tachycardia (140 beats per minute); on physical examination, he had tremor in his hands, looked pale, and was eupneic, with normal breath sounds and weak radial pulse. A 12-lead electrocardiogram (ECG) was obtained [aspecific alteration of ventricular repolarization, corrected QT (QTc) interval 467 ms], together with blood samples, showing normal troponin-T serum level. Therefore, a normal saline infusion was started.\nClinical conditions swiftly worsened in the following 30 minutes as the patient suffered faintness, extreme pallor, and cold extremities. His vital signs revealed 84% oxygen saturation on room air, hypotension (90/40 mmHg), and tachycardia (140 beats per minute). A blood gas test was conducted, showing metabolic acidosis with elevated blood lactate levels, hypokalemia, and hyperglycemia. As these findings were consistent with β2-receptor-agonist side effects, salbutamol was discontinued. Consequently, two boluses of Ringer’s acetate were administered, each over 20 minutes, because of persistent hypotension; hypokalemia was treated with 500 mL normal saline and 40 mEq/L of potassium chloride at 70 mL/hour rate of infusion in 3 hours; oxygen supplementation was started with Venturi mask providing a maximum FiO2 of 0.3.\nThe patient was subsequently admitted to our intensive observation unit. During the observation period, the patient remained eupneic without expiratory wheezing. Hypokalemia quickly reverted, whereas lactic acidosis (peak concentration 8.1 mmol/L) and lower DBP persisted for a longer time. Oxygen supplementation was discontinued overnight, maintenance normal saline was continued, and diuresis remained normal. Fluid boluses had been stopped because of persistent lower DBP with normal systolic blood pressure. Ipratropium bromide was administered alone as bronchodilator treatment at 4-hour intervals.\nTwenty-four hours later, another 12-lead ECG was performed (sinus rhythm, normal QTc). A pediatric cardiology consultation excluded any evidence of compromised left ventricular function and cardiac output and suggested that the aforementioned ECG alterations might have had a multifactorial origin (mild fever, hypokalemia, and β2-agonist toxicity).\nThe patient was eventually discharged in good clinical condition with oral betamethasone 1 mg/kg for 3 days and nebulized ipratropium bromide 0.5 mg four times a day. A drug challenge with 0.2 mg of inhaled salbutamol with spacer performed 1 week later was uneventful.", + "fulltext_subclaims": [ + "The patient was a 12-year-old Italian boy.", + "The patient weighed 34 kg.", + "The patient had a 24-hour history of intermittent chest pain.", + "The patient had a 24-hour history of cough.", + "The patient had a 24-hour history of wheezing.", + "The patient had a 24-hour history of mild fever.", + "The patient's medications prior to arrival consisted of 0.2 mg of inhaled salbutamol every 3 hours.", + "The salbutamol was initiated the previous day without medical advice.", + "The last salbutamol administration had been performed 1 hour before arrival.", + "The patient had no inciting exercise.", + "The patient used hypoallergenic material in his bedroom.", + "The salbutamol inhaler had been prescribed by his pneumologist.", + "The salbutamol was part of the patient’s asthma action plan.", + "Montelukast treatment was discontinued 5 days earlier.", + "The montelukast discontinuation was on the advice of his pneumologist.", + "The montelukast had been used for a 3-month period without asthma exacerbations.", + "The patient’s past medical history included intermittent asthma induced by exercise.", + "The patient’s past medical history included intermittent asthma induced by dust mites.", + "The asthma was diagnosed 1 year earlier.", + "Only one mild exacerbation occurred 9 months following diagnosis.", + "The exacerbation did not require hospitalization.", + "At that time, hypoallergenic material was not available in his bedroom.", + "At presentation, heart rate was 110 beats per minute.", + "At presentation, respiratory rate was 38 breaths per minute.", + "At presentation, oxygen saturation was 94% on room air.", + "At presentation, temperature was 37.1 °C.", + "Physical examination showed intercostal and substernal retractions.", + "Physical examination showed diffuse reductions in normal breath sound.", + "Physical examination showed end-expiratory wheezing.", + "The patient’s ability to speak was not affected.", + "A pediatric asthma score of 9 was calculated.", + "The patient was diagnosed with moderate asthma attack.", + "The patient was treated with 40 mg intravenous methylprednisolone.", + "The patient received 3.75 mg nebulized salbutamol.", + "The patient received 0.5 mg ipratropium bromide.", + "Three oxygen-driven nebulizations were performed.", + "Five minutes after the end of the third nebulization, a presyncope episode occurred.", + "At onset, vital signs were normal apart from tachycardia (140 beats per minute).", + "On physical examination, the patient had tremor in his hands.", + "On physical examination, the patient looked pale.", + "On physical examination, the patient was eupneic.", + "On physical examination, breath sounds were normal.", + "On physical examination, the patient had a weak radial pulse.", + "A 12-lead electrocardiogram showed aspecific alteration of ventricular repolarization.", + "The QTc interval was 467 ms.", + "Blood samples showed normal troponin-T serum level.", + "A normal saline infusion was started.", + "Clinical conditions worsened in the following 30 minutes.", + "The patient suffered faintness.", + "The patient had extreme pallor.", + "The patient had cold extremities.", + "Oxygen saturation was 84% on room air.", + "The patient had hypotension (90/40 mmHg).", + "The patient had tachycardia (140 beats per minute).", + "A blood gas test showed metabolic acidosis.", + "A blood gas test showed elevated blood lactate levels.", + "A blood gas test showed hypokalemia.", + "A blood gas test showed hyperglycemia.", + "These findings were consistent with β2-receptor-agonist side effects.", + "Salbutamol was discontinued.", + "Two boluses of Ringer’s acetate were administered.", + "Each bolus was over 20 minutes.", + "Hypokalemia was treated with 500 mL normal saline.", + "Hypokalemia was treated with 40 mEq/L of potassium chloride.", + "The potassium chloride was infused at 70 mL/hour rate in 3 hours.", + "Oxygen supplementation was started with Venturi mask.", + "The Venturi mask provided a maximum FiO2 of 0.3.", + "The patient was admitted to the intensive observation unit.", + "During the observation period, the patient remained eupneic.", + "During the observation period, there was no expiratory wheezing.", + "Hypokalemia quickly reverted.", + "Lactic acidosis persisted for a longer time.", + "The peak lactate concentration was 8.1 mmol/L.", + "Lower DBP persisted for a longer time.", + "Oxygen supplementation was discontinued overnight.", + "Maintenance normal saline was continued.", + "Diuresis remained normal.", + "Fluid boluses had been stopped.", + "Ipratropium bromide was administered alone as bronchodilator treatment.", + "Ipratropium bromide was administered at 4-hour intervals.", + "Twenty-four hours later, another 12-lead ECG was performed.", + "The ECG showed sinus rhythm.", + "The ECG showed normal QTc.", + "A pediatric cardiology consultation excluded compromised left ventricular function.", + "A pediatric cardiology consultation excluded compromised cardiac output.", + "The ECG alterations might have had a multifactorial origin.", + "The multifactorial origin included mild fever.", + "The multifactorial origin included hypokalemia.", + "The multifactorial origin included β2-agonist toxicity.", + "The patient was discharged in good clinical condition.", + "The patient received oral betamethasone 1 mg/kg for 3 days.", + "The patient received nebulized ipratropium bromide 0.5 mg four times a day.", + "A drug challenge with 0.2 mg of inhaled salbutamol with spacer was performed 1 week later.", + "The drug challenge was uneventful." + ], + "summary": "We present the case of a 12-year-old Italian boy, 34 kg body weight, who experienced a serious drug reaction during a moderate asthma exacerbation with associated dehydration (blood urea nitrogen/creatinine 0.25), following intermittent inhaled (0.2 mg at 3-hour intervals-overall 1.4 mg in 24 hours before arrival) and nebulized treatment (3.25 mg at 20-minute intervals in 60 minutes, overall 11.25 mg in our emergency department). The patient developed hyperglycemia (peak concentration 222 mg/dL), hypokalemia (lowest concentration 2.6 mEq/L), electrocardiogram alterations (corrected QT interval 467 ms), long-lasting arterial hypotension despite fluid boluses (lowest value 87/33 mmHg), and elevated blood lactate levels (peak concentration 8.1 mmol/L), following the third nebulized dose. Infections, liver dysfunction, and toxicity following other medications were ruled out. The aforementioned alterations improved within 24 hours after discontinuation of salbutamol.", + "summary_subclaims": [ + "The patient was a 12-year-old Italian boy.", + "The patient weighed 34 kg.", + "The patient experienced a serious drug reaction.", + "The reaction occurred during a moderate asthma exacerbation.", + "The patient had associated dehydration.", + "The blood urea nitrogen/creatinine ratio was 0.25.", + "The patient received intermittent inhaled salbutamol.", + "The inhaled salbutamol dose was 0.2 mg at 3-hour intervals.", + "The overall inhaled salbutamol dose in 24 hours before arrival was 1.4 mg.", + "The patient received nebulized salbutamol.", + "The nebulized salbutamol dose was 3.25 mg at 20-minute intervals in 60 minutes.", + "The overall nebulized salbutamol dose in the emergency department was 11.25 mg.", + "The patient developed hyperglycemia.", + "The peak blood glucose concentration was 222 mg/dL.", + "The patient developed hypokalemia.", + "The lowest potassium concentration was 2.6 mEq/L.", + "The patient had electrocardiogram alterations.", + "The corrected QT interval was 467 ms.", + "The patient had long-lasting arterial hypotension despite fluid boluses.", + "The lowest blood pressure was 87/33 mmHg.", + "The patient had elevated blood lactate levels.", + "The peak lactate concentration was 8.1 mmol/L.", + "The alterations occurred following the third nebulized dose.", + "Infections were ruled out.", + "Liver dysfunction was ruled out.", + "Toxicity following other medications was ruled out.", + "The alterations improved within 24 hours after discontinuation of salbutamol." + ] + }, + { + "id": "multiclinsum_test_2825_en.txt", + "fulltext": "A 75-year-old man presented with a chief complaint of abdominal discomfort and weight loss. His medical history included hypertension, paroxysmal atrial fibrillation, and refractory pruritus. He had lost approximately 10 kg of weight in 2 months and was referred to our hospital because of abdominal discomfort. At the time of consultation, his height was 174.8 cm, body weight was 56.5 kg, body mass index was 18.49; his vital signs were as follows: body temperature 36.1 °C, blood pressure 128/79 mmHg, heart rate at 77/min, and oxygen saturation at 97 % (room air). Hematological investigations performed on admission revealed carcinoembryonic antigen at 5.1 ng/mL, carbohydrate antigen19-9 at 0.1 U/mL, and carbohydrate antigen − 125 at 7.7 U/mL, indicating no increase in tumor markers. No abnormalities were observed in the blood tests. Esophagogastroduodenoscopy showed a wide, shallow, depressed lesion from the cardia to the mid-body, with an ulcerated part, which we diagnosed as a type 3 tumor . In addition, approximately 40 mm of the entire circumference of the esophagus was invaded . The lesions were diagnosed in Group5 (por, sig). Based on the biopsy results, all lesions in the ulcer presented as a wide shallow depressed lesion in the mid-body and lesions at the esophagogastric junction. Upper gastrointestinal examination showed that, on the oral side, lesions had an irregular wall and poor progression up to approximately 40 mm from the esophagogastric junction. On the anal side, they extended around the mid-body . We found an ulcerative lesion near the cardia and suspected invasion at the depth of the muscularis propria (MP). Abdominal computed tomography (CT) showed an irregularly thickened wall on the upper body and lesser curvature of the body, and an increase in the concentration of fatty tissue around the wall was also found in the mid-body . Therefore, the degree of invasion was determined to be at the depth of MP. There were no findings of suspected lymph node enlargement or metastases to other organs. Considering these facts, we preoperatively diagnosed gastric cancer as T2, N0, M0, StageIB (according to the UICC, 8th edition). We performed a total gastrectomy with abdominal esophageal resection, D2 lymph node dissection, cholecystectomy, and Roux-en-Y reconstruction. The proximal side of the invasive esophageal area (40 mm from the esophagogastric junction) was clipped as a marker preoperatively. Intraoperatively, it was confirmed that there was no cancer at the esophageal margin and that it was resected, including the clip. The excised specimen showed a shallow depressed lesion of 90×55 mm from the abdominal esophagus to the lesser curvature of the upper stomach, and a type 0-IIb + IIa + IIc lesion (according to the macroscopic classification of the gastric cancer) with esophageal invasion up to 30 mm from the esophagogastric junction . Histopathological findings showed that all widespread lesions were cancers that remained in the mucosa, with por2 being the majority and some sig being mixed. No submucosal invasion was observed, including in the ulcerated area . The pathological diagnosis was gastric cancer: T1a, N0, M0, and StageIA. The postoperative course was uneventful and the patient was discharged on POD 11. Five years since the operation, the patient is surviving without recurrence.", + "fulltext_subclaims": [ + "The patient is a 75-year-old man.", + "The patient's chief complaint was abdominal discomfort.", + "The patient had lost approximately 10 kg of weight in 2 months.", + "The patient was referred to the hospital because of abdominal discomfort.", + "The patient's body mass index was 18.49.", + "The patient's blood pressure was 128/79 mmHg.", + "The patient's oxygen saturation was 97% on room air.", + "Hematological investigations showed carcinoembryonic antigen at 5.1 ng/mL.", + "Hematological investigations showed carbohydrate antigen19-9 at 0.1 U/mL.", + "Hematological investigations showed carbohydrate antigen − 125 at 7.7 U/mL.", + "No increase in tumor markers was indicated.", + "No abnormalities were observed in the blood tests.", + "Esophagogastroduodenoscopy showed a wide, shallow, depressed lesion from the cardia to the mid-body.", + "The lesion was diagnosed as a type 3 tumor.", + "Approximately 40 mm of the entire circumference of the esophagus was invaded.", + "The lesions were diagnosed in Group5 (por, sig).", + "Upper gastrointestinal examination showed lesions with an irregular wall and poor progression up to approximately 40 mm from the esophagogastric junction.", + "An ulcerative lesion near the cardia was suspected to invade at the depth of the muscularis propria.", + "Abdominal computed tomography showed an irregularly thickened wall on the upper body and lesser curvature of the body.", + "The degree of invasion was determined to be at the depth of the muscularis propria.", + "There were no findings of suspected lymph node enlargement.", + "There were no findings of metastases to other organs.", + "The preoperative diagnosis was gastric cancer T2, N0, M0, StageIB.", + "A total gastrectomy with abdominal esophageal resection was performed.", + "A D2 lymph node dissection was performed.", + "A cholecystectomy was performed.", + "A Roux-en-Y reconstruction was performed.", + "The proximal side of the invasive esophageal area was clipped as a marker preoperatively.", + "Intraoperatively, it was confirmed that there was no cancer at the esophageal margin.", + "The excised specimen showed a shallow depressed lesion of 90×55 mm from the abdominal esophagus to the lesser curvature of the upper stomach.", + "The lesion was classified as type 0-IIb + IIa + IIc.", + "Histopathological findings showed that all widespread lesions were cancers that remained in the mucosa.", + "No submucosal invasion was observed, including in the ulcerated area.", + "The pathological diagnosis was gastric cancer: T1a, N0, M0, StageIA.", + "The patient was discharged on postoperative day 11.", + "Five years since the operation, the patient is surviving without recurrence." + ], + "summary": "A 75-year-old man presented with a chief complaint of abdominal discomfort and weight loss. Esophagogastroduodenoscopy revealed an irregular ulcerative lesion with partial redness of the upper body and lesser curve of the stomach. A continuous shallow depressed lesion invaded the abdominal esophagus by approximately 40 mm. Poorly differentiated adenocarcinomas (por, sig) were observed on biopsy. Grossly, the cancer appeared to extend into the muscle layer; however, we could not confirm invasion into the muscle layer in our biopsy tissue. We diagnosed the lesion as a superficial spreading type of advanced gastric cancer and performed a total gastrectomy, D2-lymph node dissection (spleen preservation), Roux-en-Y reconstruction, and cholecystectomy. Postoperative histopathological examination revealed extensive infiltration of poorly differentiated adenocarcinoma (90 mm × 55 mm), and all were intramucosal lesions. The final pathological diagnosis was T1a, N0, M0, and Stage IA. The postoperative course was uneventful and the patient was discharged on postoperative day (POD) 11. Five years have passed since the operation, and the patient is alive without recurrence.", + "summary_subclaims": [ + "The patient is a 75-year-old man.", + "The patient's chief complaint was abdominal discomfort and weight loss.", + "Esophagogastroduodenoscopy revealed an irregular ulcerative lesion with partial redness of the upper body and lesser curve of the stomach.", + "A continuous shallow depressed lesion invaded the abdominal esophagus by approximately 40 mm.", + "Poorly differentiated adenocarcinomas (por, sig) were observed on biopsy.", + "Grossly, the cancer appeared to extend into the muscle layer.", + "We could not confirm invasion into the muscle layer in our biopsy tissue.", + "The lesion was diagnosed as a superficial spreading type of advanced gastric cancer.", + "A total gastrectomy was performed.", + "A D2-lymph node dissection (spleen preservation) was performed.", + "A Roux-en-Y reconstruction was performed.", + "A cholecystectomy was performed.", + "Postoperative histopathological examination revealed extensive infiltration of poorly differentiated adenocarcinoma (90 mm × 55 mm).", + "All were intramucosal lesions.", + "The final pathological diagnosis was T1a, N0, M0, and Stage IA.", + "The postoperative course was uneventful.", + "The patient was discharged on postoperative day 11.", + "Five years have passed since the operation.", + "The patient is alive without recurrence." + ] + }, + { + "id": "multiclinsum_test_1869_en.txt", + "fulltext": "A 72-year-old, para one Caucasian female, presented with postmenopausal bleeding in July 2016. Her past medical history was significant for hypertension managed by Hydrochlorothiazide. She had no family history of ovarian, uterine, breast, pancreas, colon, or prostate cancer. Social history included social drinking with 1–2 drinks per week, with no smoking or recreational substance use. Her BMI was 27, and Eastern Cooperative Oncology Group Performance Status (ECOG PS) score was 0, denoting that she was fully active and able to perform activities without restriction. The ECOG PS is a scale describing a patient's functional status regarding their ability to take care of themselves and perform daily and physical activities. An endometrial biopsy showed clear cell carcinoma of the endometrium. A CT-Abdomen/Pelvis (CT-AP) was consistent with thick endometrium, unremarkable adnexal structures, and no evidence of metastatic disease. CA19-9 and CA-125 were 168.9 μ/mL and 68.1 μ/mL respectively. Upon final review of the patient's history and physical, she was found to be optimized for surgery. She underwent a robot-assisted total laparoscopic hysterectomy, bilateral salpingo-oophorectomy, omentectomy and pelvic and para-aortic lymph node dissection by a gynecologic oncologist. Pathology showed mixed endometrioid and clear cell adenocarcinoma with 90 % myometrial invasion, positive metastatic adenocarcinoma to multiple pelvic and paraaortic lymph nodes bilaterally, no omental metastasis, and negative pelvic washings. This was consistent with FIGO stage IIIC2, grade 2 endometrioid adenocarcinoma/clear cell carcinoma. She was treated with adjuvant chemotherapy with platinum and taxane doublet IV every 21 days for a total of six cycles. During immediate post-chemotherapy surveillance, there was no evidence of residual disease on CT scan, and serial CA 125 levels decreased appropriately. Twenty months after initial debulking, CA125 levels were noted to double over a five-month period . Patient had no presenting symptoms and the physical exam was without evidence of recurrence.", + "fulltext_subclaims": [ + "The patient is a 72-year-old, para one Caucasian female.", + "She presented with postmenopausal bleeding in July 2016.", + "Her past medical history was significant for hypertension managed by Hydrochlorothiazide.", + "She had no family history of ovarian, uterine, breast, pancreas, colon, or prostate cancer.", + "Her social history included social drinking with 1–2 drinks per week.", + "She had no smoking or recreational substance use.", + "Her BMI was 27.", + "Her ECOG PS score was 0.", + "An endometrial biopsy showed clear cell carcinoma of the endometrium.", + "A CT-Abdomen/Pelvis was consistent with thick endometrium.", + "The CT-Abdomen/Pelvis showed unremarkable adnexal structures.", + "The CT-Abdomen/Pelvis showed no evidence of metastatic disease.", + "CA19-9 was 168.9 μ/mL.", + "CA-125 was 68.1 μ/mL.", + "She underwent a robot-assisted total laparoscopic hysterectomy.", + "She had a bilateral salpingo-oophorectomy.", + "She had an omentectomy.", + "She had a pelvic and para-aortic lymph node dissection.", + "Pathology showed mixed endometrioid and clear cell adenocarcinoma.", + "There was 90 % myometrial invasion.", + "There was positive metastatic adenocarcinoma to multiple pelvic and paraaortic lymph nodes bilaterally.", + "There was no omental metastasis.", + "Pelvic washings were negative.", + "This was consistent with FIGO stage IIIC2.", + "This was consistent with grade 2 endometrioid adenocarcinoma/clear cell carcinoma.", + "She was treated with adjuvant chemotherapy with platinum and taxane doublet IV every 21 days.", + "She received six cycles of adjuvant chemotherapy.", + "During immediate post-chemotherapy surveillance, there was no evidence of residual disease on CT scan.", + "Serial CA 125 levels decreased appropriately.", + "Twenty months after initial debulking, CA125 levels were noted to double over a five-month period.", + "The patient had no presenting symptoms.", + "The physical exam was without evidence of recurrence." + ], + "summary": "A 72 year-old female patient presented with postmenopausal bleeding and was subsequently diagnosed with Stage IIIC2 clear cell carcinoma of the endometrium. She represented 20 months after receiving initial staging and adjuvant chemotherapy with increasing CA-125 levels and radiographic evidence of left para-aortic lymph node oligo metastasis. She underwent secondary cytoreductive surgery via robotic-assisted laparoscopic para-aortic lymph node dissection and salvage chemotherapy. After 45 months of follow-up physical exam, CA-125 levels and CT of the abdomen and pelvis have remained without evidence of disease.", + "summary_subclaims": [ + "The patient is a 72 year-old female.", + "The patient presented with postmenopausal bleeding.", + "The patient was diagnosed with Stage IIIC2 clear cell carcinoma of the endometrium.", + "The patient represented 20 months after receiving initial staging.", + "The patient had adjuvant chemotherapy.", + "The patient had increasing CA-125 levels.", + "There was radiographic evidence of left para-aortic lymph node oligo metastasis.", + "The patient underwent secondary cytoreductive surgery.", + "The surgery was via robotic-assisted laparoscopic para-aortic lymph node dissection.", + "The patient received salvage chemotherapy.", + "After 45 months of follow-up, there was no evidence of disease." + ] + }, + { + "id": "multiclinsum_test_694_en.txt", + "fulltext": "A 15-year-old girl presented to our clinic with long-term nasal obstruction, which was bilaterally and more severe on the left side. The initial examination revealed that the patient had no history of epistaxis, trauma, headache, previous rhinoplasty, or constitutional symptoms. Moreover, the case lacked a history of any drug abuse, cocaine, and long-term nasal sprays. She also lacked any drug allergies and was healthy in other aspects, and the results of routine laboratory tests were normal. In the anterior rhinoscopy, a mass on the mucosal surface was observed, which almost completely filled the right nasal cavity. On the left side, there was a very severe nasal septal deviation that almost reached the lateral wall of the left nasal cavity. The endoscopic exam of the case showed a huge middle turbinate on the right nasal cavity that compressed the mid-portion of the nasal septum and made it deviate to the left side. Due to severe nasal septal deviation, the endoscope did not pass through the left side. No perforation was observed through the endoscopy. Since the endoscopic exam was not satisfactory, we requested a computed tomography (CT) scan of the paranasal sinuses without contrast to evaluate the whole system. Computed tomography imaging was consistent with giant CB on the right nasal cavity that passed through the nasal septum and extended somehow through the nasal septum. The septum seemed to be perforated, and there was a severe nasal septum deviation to the left side. This imaging also showed bilateral pneumatized superior concha and hypertrophic inferior conchae on the left side; nevertheless, no sinusitis was observed .\nAccording to , giant concha bullosa on the right nasal cavity passed through the nasal septum and extended through the nasal septum, and the septum perforation can be noticed.\nThe patient was scheduled for surgery. Functional endoscopic sinus operation was performed under general anesthesia. After local anesthesia, 2 ml of 2% lidocaine and epinephrine 1: 100,000 was injected along the anterior parts of the middle turbinate. Separated the outer and inner slices of the large middle concha, and then, resect the inner slice to assess the nasal septum. The middle turbinate had pneumatized in preference to the anterior ethmoid cells. As expected, there was a circular perforation with preserved mucosa on its margins. As the pressure was reduced, we managed to perform an endoscopy on the left side .\nHistopathological examination of the excised lesion revealed fibroconnective tissue and inflammatory cell infiltration with no evidence of granulomatous reaction or malignancy. Purified protein derivative skin test was considered negative and perinuclear anti-neutrophil cytoplasmic antibodies (p-ANCA) and classic-ANCA and angiotensin-converting enzyme levels were within normal range. Chest X-ray examination was normal. The microbial smear and culture of the specimen were negative. After the operation, the patient's symptoms alleviated rapidly.", + "fulltext_subclaims": [ + "The patient is a 15-year-old girl.", + "The patient had long-term nasal obstruction.", + "The nasal obstruction was bilaterally present.", + "The nasal obstruction was more severe on the left side.", + "The patient had no history of epistaxis.", + "The patient had no history of trauma.", + "The patient had no history of headache.", + "The patient had no history of previous rhinoplasty.", + "The patient had no history of constitutional symptoms.", + "The patient had no history of drug abuse.", + "The patient had no history of cocaine use.", + "The patient had no history of long-term nasal sprays.", + "The patient had no drug allergies.", + "The patient was healthy in other aspects.", + "The results of routine laboratory tests were normal.", + "Anterior rhinoscopy revealed a mass on the mucosal surface.", + "The mass almost completely filled the right nasal cavity.", + "The left side had a very severe nasal septal deviation.", + "The nasal septal deviation almost reached the lateral wall of the left nasal cavity.", + "The endoscopic exam showed a huge middle turbinate on the right nasal cavity.", + "The middle turbinate compressed the mid-portion of the nasal septum.", + "The nasal septum was deviated to the left side.", + "The endoscope did not pass through the left side.", + "No perforation was observed through the endoscopy.", + "A computed tomography (CT) scan of the paranasal sinuses without contrast was requested.", + "Computed tomography imaging was consistent with giant concha bullosa on the right nasal cavity.", + "The giant concha bullosa passed through the nasal septum.", + "The giant concha bullosa extended through the nasal septum.", + "The septum seemed to be perforated.", + "There was a severe nasal septum deviation to the left side.", + "The imaging showed bilateral pneumatized superior concha.", + "The imaging showed hypertrophic inferior conchae on the left side.", + "No sinusitis was observed.", + "The patient was scheduled for surgery.", + "Functional endoscopic sinus operation was performed under general anesthesia.", + "2 ml of 2% lidocaine and epinephrine 1:100,000 was injected along the anterior parts of the middle turbinate.", + "The outer and inner slices of the large middle concha were separated.", + "The inner slice was resected to assess the nasal septum.", + "The middle turbinate had pneumatized in preference to the anterior ethmoid cells.", + "There was a circular perforation with preserved mucosa on its margins.", + "An endoscopy on the left side was performed after pressure was reduced.", + "Histopathological examination revealed fibroconnective tissue.", + "Histopathological examination revealed inflammatory cell infiltration.", + "There was no evidence of granulomatous reaction.", + "There was no evidence of malignancy.", + "Purified protein derivative skin test was considered negative.", + "p-ANCA levels were within normal range.", + "Classic-ANCA levels were within normal range.", + "Angiotensin-converting enzyme levels were within normal range.", + "Chest X-ray examination was normal.", + "Microbial smear of the specimen was negative.", + "Microbial culture of the specimen was negative.", + "The patient's symptoms alleviated rapidly after the operation." + ], + "summary": "The case of this report was a 15-year-old female who presented with long-term nasal obstruction due to a huge concha bullosa in her right nasal cavity which perforated nasal septum. She lacked a history of any nasal septum surgery, drug abuse, cocaine, or long-term nasal spray. Endoscopic surgery was performed and our patient's symptoms rapidly diminished after the surgery. Negative results were obtained for tuberculosis, Wegener's granulomatosis disease, and malignancy.", + "summary_subclaims": [ + "The patient was a 15-year-old female.", + "She presented with long-term nasal obstruction.", + "The nasal obstruction was due to a huge concha bullosa in her right nasal cavity.", + "The concha bullosa perforated the nasal septum.", + "She lacked a history of any nasal septum surgery.", + "She lacked a history of drug abuse.", + "She lacked a history of cocaine use.", + "She lacked a history of long-term nasal spray use.", + "Endoscopic surgery was performed.", + "The patient's symptoms rapidly diminished after the surgery.", + "Negative results were obtained for tuberculosis.", + "Negative results were obtained for Wegener's granulomatosis disease.", + "Negative results were obtained for malignancy." + ] + }, + { + "id": "multiclinsum_test_39_en.txt", + "fulltext": "A 12 year old girl initially presented at 6 years of age with exercise intolerance. She was born to non-consanguineous healthy parents. She has two younger, healthy brothers although one has autistic spectrum disorder. She presented with shortness of breath with low-intensity aerobic exercise such as jogging or biking. She had no chest pain or palpitations. Cardiac examination at 7 years old noted a normal clinical examination however her electrocardiogram revealed biventricular hypertrophy. Subsequent echocardiogram and cardiac MRI identified thickening of the posterior left ventricle (LV) wall, apex and septum consistent with a non-compaction cardiomyopathy. Bilateral ventricular systolic and diastolic function was normal with a LV ejection fraction of 63%. Stress testing confirmed a normal baseline heart rate, blood pressure and a normal response to exercise. Pulmonary function tests were normal. Biochemical testing revealed normal serum creatine kinase (CK) with a slight elevation of serum troponin T. Genetic testing included normal SCN5A sequencing, chromosomal microarray and hypertrophic and dilated cardiomyopathy panel (GeneDx, Gaithersburg, MD).\nOver the next year, she reported exercise-induced myalgia. She had no muscle weakness, cramping or pigmenturia. She could perform short bursts of anaerobic activity without difficulty however, sustained activity would elicit muscle pain. Biochemical testing was abnormal on multiple occasions including: plasma lactate (2.3 – 4.6 mmol/L; normal 0.5 - 2.2 mmol/L) and plasma alanine (603 - 841 μmol /L; normal 152 - 547 μmol/L). Her acylcarnitine profile and carnitine levels (free and total) were normal as was urine organic acid analysis. Repeated serum CK, liver and renal function were normal. Neuromuscular assessment at 9 years of age showed her cranial nerves, muscle power, reflexes, sensory testing and coordination to be within normal limits. Gower manoeuvre was negative and gait was normal. Electrodiagnostic testing confirmed normal right median and sural nerve sensory responses and normal right median and tibial nerve motor responses. Concentric needle electromyography of her right quadriceps was normal.\nMuscle biopsy of the quadriceps performed at 9 years of age revealed a preponderance of type 1 fibers although no other microscopic, histochemical or ultrastructural abnormalities were apparent. Muscle respiratory chain enzyme testing and muscle mitochondrial DNA sequencing was normal. MRI of the brain at 10 years of age revealed abnormal T2 and T2FLAIR hyperintensity in the periventricular and trigonal white matter bilaterally. MR spectroscopy of the basal ganglia and subcortical white matter was normal. MRI of the proximal leg muscles was unremarkable. Treatment with ubiquinone, vitamin B50 complex, levocarnitine and ubiquinol were started at 10 years old without apparent clinical effect. Creatine monohydrate was added several months later after which she reported a sustained, subjective clinical improvement in her exercise tolerance.\nNeuromuscular evaluation at 12 years old was significant for bilateral extensor hallucis longus and extensor digitorum brevis weakness (4/5). Strength testing of all other muscles was within normal limits. Cranial nerve testing, deep tendon reflexes, sensory testing and coordination were within normal limits. Repeat neurophysiological testing revealed a reduction in her right common peroneal nerve motor response due to a slight CMAP amplitude reduction of 2.1 mV (normal >2.4 mV). Motor responses at the left peroneal, right tibial, right median and ulnar nerves were normal. Sensory responses at the right median, ulnar, superficial peroneal and sural nerves were normal. Concentric needle EMG of the right tibialis anterior and medial gastrocnemius was normal. Her most recent cardiac evaluation at 12 years old identified two new findings: electrocardiogram identified a new subclinical Wolf-Parkinson-White pre-excitation that was not noted on prior studies as well as evidence for LV diastolic dysfunction on echocardiogram.\nHer medical history was otherwise unremarkable. She was born at term with no complications. Early milestones were appropriate; she sat at 6 months old, pulled to stand by 12 months and walked independently by 18 months of age. Her growth parameters were stable; height (just <50th percentile) and weight (just < 25th percentile) following along her percentile curves from infancy. She has never had any seizures, headaches or endocrine dysfunction. She has no oculobulbar symptoms and no sensory or autonomic dysfunction. Her visual acuity and hearing were normal. She excelled academically, achieving high grades in a gifted program.\nWe followed standard manufacturer protocols to perform target capture with the Agilent SureSelect All Exon 50 MB (V3) exome enrichment kit and sequencing of 100 bp paired end reads on Illumina Hiseq 2000, which generated over 12.4 Gb of data for the proband. We removed adaptor sequences and quality trimmed reads using the Fastx toolkit and then used a custom script to ensure that only read pairs with both mates present were subsequently used. Reads were aligned to hg19 with BWA 0.5.9 and indel realignment was done using the GATK . Duplicate reads were then marked using Picard and excluded from downstream analyses. We assessed coverage of consensus coding sequence (CCDS) bases using the GATK, which showed that all samples had >91% of CCDS bases covered by at least 10 reads, and >85% of CCDS bases covered by at least 20 reads. Single nucleotide variants (SNVs) and short insertions and deletions (indels) were called using samtools mpileup with the extended base alignment quality (BAQ) adjustment (-E), and were then quality filtered to require at least 20% of reads supporting the variant call. Variants were annotated using both Annovar and custom scripts to identify whether they affected protein coding sequence, and whether they had previously been seen in dbSNP132, the 1000 genomes dataset (Nov 2011), the NHLBI GO exomes, or in approximately 500 exomes previously sequenced at our center.\nGiven the suspicion of a mitochondrial disorder based on the patient’s clinical phenotype, we first filtered the list of non-synonymous variants to retain only those present in genes in the MitoCarta Inventory of Mammalian Mitochondrial Genes and which were seen in 7 or fewer internal control exomes (of ~500) and at less than 1% frequency in the 1000 genomes and NHLBI GO exome databases. There were 13 genes with single heterozygous variants, and a single gene, GARS, with two rare heterozygous variants. The two GARS variants, NM_002047.2: c.1904C > T (p.Ser635Leu) and c.1787G > A (p.Arg596Gln) occur at highly conserved positions and are predicted to be deleterious by both SIFT (scores 0.01 and 0.00, respectively) and PolyPhen2 (scores 0.94 and 1.00, respectively). We then analyzed the remaining exome data and no convincing disease-causing variants were identified in any other genes relevant to previously reported neuromuscular disorders.\nWe identified our patient to have a sequence variant in the MIB1 (mindbomb E3 ubiquitin protein ligase 1) gene which has been linked to non-compaction cardiomyopathy. Our patient’s MIB1 sequence variant has not been previously reported but did occur in a highly conserved region of this gene. We confirmed that the proband’s father carries the same MIB1 sequence variant although he shows no evidence of cardiomyopathy on clinical examination or echocardiogram.\nSanger sequencing was used to validate the variants in GARS and to evaluate segregation in the family. Blood samples were obtained and DNA was extracted from the patient as well as her parents and two unaffected siblings. PCR amplification and sequencing was performed with primers 5′CAGATGATCCACCTACCTCAG3′ and 5′ATAACACAGGAAACTGGTTTGTC-3′ to test the c.1787G > A variant. PCR amplification was performed using 5′AGTGAAGATTTGGATTCCCG-3′ and 5′GGACTTGAGAATCTGGGCTC3′ primers and Sanger sequencing was done using 5′AAGAAGCAGTACACATTTCTAAG-3 and 5′GTAAGACAGTAGTTAGATAAC-3 primers, to test the c.1904C > T variant.\nSanger sequencing confirmed the presence of these variants in the proband. The parents were each heterozygous for one of the mutations; c.1787G > A was inherited from her mother and c.1904C > T was inherited from her father . The c.1904C > T mutation has previously been reported to be disease-causing [,], the reported patient exhibited a clinical phenotype characterized by adolescent-onset foot deformity necessitating an orthopedic referral at the age 27 years old.\nGiven the findings of recessive mutations in GARS and the knowledge that heterozygous mutations in this gene can cause disease, the family was evaluated in detail. The proband’s father reported no weakness or sensory deficits when examined at 55 years old. His clinical examination was entirely within normal limits. His electrodiagnostic testing, however, revealed evidence of a mild sensorimotor polyneuropathy with axonal features. Bilateral sural and superficial peroneal nerve sensory amplitudes were low. His common peroneal and tibial motor amplitudes were within normal limits. Concentric needle EMG of his right extensor digitorum brevis and abductor hallucis revealed fibrillation potentials and positive sharp waves in addition to chronic neurogenic changes. Needle EMG of his right tibialis anterior also revealed chronic neurogenic changes. The proband’s mother reported no functional difficulty. Her clinical examination, echocardiogram and nerve conduction studies at age 47 years old were within normal limits. Needle EMG was not performed. The proband’s two younger brothers had no significant findings on clinical examination or nerve conduction testing.", + "fulltext_subclaims": [ + "The patient is a 12 year old girl.", + "She initially presented at 6 years of age with exercise intolerance.", + "She was born to non-consanguineous healthy parents.", + "She has two younger, healthy brothers.", + "One of her brothers has autistic spectrum disorder.", + "She presented with shortness of breath with low-intensity aerobic exercise.", + "She had no chest pain.", + "She had no palpitations.", + "Cardiac examination at 7 years old noted a normal clinical examination.", + "Her electrocardiogram at 7 years old revealed biventricular hypertrophy.", + "Subsequent echocardiogram and cardiac MRI identified thickening of the posterior left ventricle (LV) wall, apex and septum.", + "The thickening was consistent with a non-compaction cardiomyopathy.", + "Bilateral ventricular systolic and diastolic function was normal.", + "Her LV ejection fraction was 63%.", + "Stress testing confirmed a normal baseline heart rate.", + "Stress testing confirmed a normal baseline blood pressure.", + "Stress testing confirmed a normal response to exercise.", + "Pulmonary function tests were normal.", + "Biochemical testing revealed normal serum creatine kinase (CK).", + "Biochemical testing revealed a slight elevation of serum troponin T.", + "Genetic testing included normal SCN5A sequencing.", + "Genetic testing included a normal chromosomal microarray.", + "Genetic testing included a normal hypertrophic and dilated cardiomyopathy panel.", + "Over the next year, she reported exercise-induced myalgia.", + "She had no muscle weakness.", + "She had no muscle cramping.", + "She had no pigmenturia.", + "She could perform short bursts of anaerobic activity without difficulty.", + "Sustained activity would elicit muscle pain.", + "Biochemical testing was abnormal on multiple occasions.", + "Plasma lactate ranged from 2.3 to 4.6 mmol/L.", + "Plasma alanine ranged from 603 to 841 μmol/L.", + "Her acylcarnitine profile was normal.", + "Her carnitine levels (free and total) were normal.", + "Urine organic acid analysis was normal.", + "Repeated serum CK, liver and renal function were normal.", + "Neuromuscular assessment at 9 years of age showed cranial nerves within normal limits.", + "Muscle power at 9 years of age was within normal limits.", + "Reflexes at 9 years of age were within normal limits.", + "Sensory testing at 9 years of age was within normal limits.", + "Coordination at 9 years of age was within normal limits.", + "Gower manoeuvre was negative.", + "Gait was normal.", + "Electrodiagnostic testing confirmed normal right median and sural nerve sensory responses.", + "Electrodiagnostic testing confirmed normal right median and tibial nerve motor responses.", + "Concentric needle electromyography of her right quadriceps was normal.", + "Muscle biopsy of the quadriceps performed at 9 years of age revealed a preponderance of type 1 fibers.", + "No other microscopic, histochemical or ultrastructural abnormalities were apparent.", + "Muscle respiratory chain enzyme testing was normal.", + "Muscle mitochondrial DNA sequencing was normal.", + "MRI of the brain at 10 years of age revealed abnormal T2 and T2FLAIR hyperintensity in the periventricular and trigonal white matter bilaterally.", + "MR spectroscopy of the basal ganglia and subcortical white matter was normal.", + "MRI of the proximal leg muscles was unremarkable.", + "Treatment with ubiquinone, vitamin B50 complex, levocarnitine and ubiquinol were started at 10 years old.", + "The treatment had no apparent clinical effect.", + "Creatine monohydrate was added several months later.", + "She reported a sustained, subjective clinical improvement in her exercise tolerance.", + "Neuromuscular evaluation at 12 years old was significant for bilateral extensor hallucis longus and extensor digitorum brevis weakness (4/5).", + "Strength testing of all other muscles was within normal limits.", + "Cranial nerve testing was within normal limits.", + "Deep tendon reflexes were within normal limits.", + "Sensory testing was within normal limits.", + "Coordination was within normal limits.", + "Repeat neurophysiological testing revealed a reduction in her right common peroneal nerve motor response.", + "The reduction was due to a slight CMAP amplitude reduction of 2.1 mV.", + "Motor responses at the left peroneal, right tibial, right median and ulnar nerves were normal.", + "Sensory responses at the right median, ulnar, superficial peroneal and sural nerves were normal.", + "Concentric needle EMG of the right tibialis anterior and medial gastrocnemius was normal.", + "Her most recent cardiac evaluation at 12 years old identified a new subclinical Wolf-Parkinson-White pre-excitation.", + "The Wolf-Parkinson-White pre-excitation was not noted on prior studies.", + "Evidence for LV diastolic dysfunction was identified on echocardiogram.", + "Her medical history was otherwise unremarkable.", + "She was born at term with no complications.", + "Early milestones were appropriate.", + "She sat at 6 months old.", + "She pulled to stand by 12 months.", + "She walked independently by 18 months of age.", + "Her growth parameters were stable.", + "Her height was just <50th percentile.", + "Her weight was just <25th percentile.", + "She has never had any seizures.", + "She has never had headaches.", + "She has no endocrine dysfunction.", + "She has no oculobulbar symptoms.", + "She has no sensory or autonomic dysfunction.", + "Her visual acuity was normal.", + "Her hearing was normal.", + "She excelled academically.", + "She achieved high grades in a gifted program.", + "Target capture was performed with the Agilent SureSelect All Exon 50 MB (V3) exome enrichment kit.", + "Sequencing of 100 bp paired end reads was done on Illumina Hiseq 2000.", + "Adaptor sequences were removed using the Fastx toolkit.", + "Reads were quality trimmed using the Fastx toolkit.", + "Reads were aligned to hg19 with BWA 0.5.9.", + "Indel realignment was done using the GATK.", + "Duplicate reads were marked using Picard.", + "Duplicate reads were excluded from downstream analyses.", + "Coverage of consensus coding sequence (CCDS) bases was assessed using the GATK.", + "All samples had >91% of CCDS bases covered by at least 10 reads.", + "All samples had >85% of CCDS bases covered by at least 20 reads.", + "Single nucleotide variants (SNVs) and short insertions and deletions (indels) were called using samtools mpileup.", + "Variants were quality filtered to require at least 20% of reads supporting the variant call.", + "Variants were annotated using Annovar.", + "Variants were annotated using custom scripts.", + "The patient’s clinical phenotype suggested a mitochondrial disorder.", + "Non-synonymous variants were filtered to retain only those in genes in the MitoCarta Inventory.", + "Variants were retained if seen in 7 or fewer internal control exomes.", + "Variants were retained if at less than 1% frequency in the 1000 genomes and NHLBI GO exome databases.", + "There were 13 genes with single heterozygous variants.", + "A single gene, GARS, had two rare heterozygous variants.", + "The two GARS variants, c.1904C > T (p.Ser635Leu) and c.1787G > A (p.Arg596Gln), occur at highly conserved positions.", + "The variants were predicted to be deleterious by SIFT.", + "The variants were predicted to be deleterious by PolyPhen2.", + "No convincing disease-causing variants were identified in any other genes.", + "A sequence variant in the MIB1 gene was identified.", + "The MIB1 gene has been linked to non-compaction cardiomyopathy.", + "The patient’s MIB1 sequence variant has not been previously reported.", + "The variant occurred in a highly conserved region of the MIB1 gene.", + "The proband’s father carries the same MIB1 sequence variant.", + "The father shows no evidence of cardiomyopathy.", + "Sanger sequencing was used to validate the variants in GARS.", + "Sanger sequencing was used to evaluate segregation in the family.", + "Blood samples were obtained from the patient, her parents and two unaffected siblings.", + "DNA was extracted from the patient, her parents and two unaffected siblings.", + "PCR amplification and sequencing was performed with primers 5′CAGATGATCCACCTACCTCAG3′ and 5′ATAACACAGGAAACTGGTTTGTC-3′ to test the c.1787G > A variant.", + "PCR amplification was performed using 5′AGTGAAGATTTGGATTCCCG-3′ and 5′GGACTTGAGAATCTGGGCTC3′ primers.", + "Sanger sequencing was done using 5′AAGAAGCAGTACACATTTCTAAG-3 and 5′GTAAGACAGTAGTTAGATAAC-3 primers to test the c.1904C > T variant.", + "Sanger sequencing confirmed the presence of these variants in the proband.", + "The parents were each heterozygous for one of the mutations.", + "The c.1787G > A mutation was inherited from her mother.", + "The c.1904C > T mutation was inherited from her father.", + "The c.1904C > T mutation has previously been reported to be disease-causing.", + "The reported patient with the c.1904C > T mutation exhibited a clinical phenotype characterized by adolescent-onset foot deformity.", + "The reported patient with the c.1904C > T mutation required an orthopedic referral at the age 27 years old.", + "The proband’s father reported no weakness.", + "The proband’s father reported no sensory deficits.", + "The proband’s father’s clinical examination was entirely within normal limits.", + "The proband’s father’s electrodiagnostic testing revealed evidence of a mild sensorimotor polyneuropathy with axonal features.", + "Bilateral sural and superficial peroneal nerve sensory amplitudes were low.", + "Common peroneal and tibial motor amplitudes were within normal limits.", + "Concentric needle EMG of his right extensor digitorum brevis and abductor hallucis revealed fibrillation potentials and positive sharp waves.", + "Needle EMG revealed chronic neurogenic changes.", + "The proband’s mother reported no functional difficulty.", + "The proband’s mother’s clinical examination was within normal limits.", + "The proband’s mother’s echocardiogram was within normal limits.", + "The proband’s mother’s nerve conduction studies were within normal limits.", + "Needle EMG was not performed on the proband’s mother.", + "The proband’s two younger brothers had no significant findings on clinical examination.", + "The proband’s two younger brothers had no significant findings on nerve conduction testing." + ], + "summary": "We report a 12-year old girl who presented with clinical and biochemical features of a systemic mitochondrial disease including exercise-induced myalgia, non-compaction cardiomyopathy, persistent elevation of blood lactate and alanine and MRI evidence of mild periventricular leukomalacia. Using exome sequencing she was found to harbor compound heterozygous mutations within the glycyl-tRNA synthetase (GARS) gene; c.1904C > T; p.Ser635Leu and c.1787G > A; p.Arg596Gln. Each mutation occurred at a highly conserved site within the anticodon binding domain.", + "summary_subclaims": [ + "The patient is a 12-year old girl.", + "She presented with clinical and biochemical features of a systemic mitochondrial disease.", + "She had exercise-induced myalgia.", + "She had non-compaction cardiomyopathy.", + "She had persistent elevation of blood lactate.", + "She had persistent elevation of blood alanine.", + "MRI showed evidence of mild periventricular leukomalacia.", + "Exome sequencing was performed.", + "She was found to harbor compound heterozygous mutations within the glycyl-tRNA synthetase (GARS) gene.", + "The mutations were c.1904C > T; p.Ser635Leu and c.1787G > A; p.Arg596Gln.", + "Each mutation occurred at a highly conserved site within the anticodon binding domain." + ] + }, + { + "id": "multiclinsum_test_35_en.txt", + "fulltext": "A 79-year-old man with advanced CKD, Stage 4, a baseline serum creatinine level of 2.04 mg/dL (normal range 0.65–1.09) and an estimated glomerular filtration rate (eGFR) of 25.5 mL/min/1.73 m2 (normal range > 90), presented with claudication. Other medical history included diabetes mellitus and hypertension. Bilateral claudication appeared 24 months prior and later worsened, on walking 10 m (Rutherford Category 3). The patient’s ankle brachial index (ABI) was 0.75 and 0.56 on the right side and left side, respectively. To avoid contrast medium administration, non-contrast MRA and vascular ultrasound were chosen for the diagnosis.\nSevere stenosis was detected at the bilateral common iliac artery (CIA) to the external iliac artery (EIA) on MRA . Doppler echo on vascular ultrasound indicated that the culprit lesion was on the CIA and/or EIA on both sides . Endovascular therapy was recommended in our multidisciplinary cardiovascular team. After discussion, the patient opted to proceed with zero-contrast EVT, with the concurrent preparation for contrast administration.", + "fulltext_subclaims": [ + "The patient is a 79-year-old man.", + "The patient has advanced CKD, Stage 4.", + "The patient’s baseline serum creatinine level is 2.04 mg/dL.", + "The patient’s estimated glomerular filtration rate is 25.5 mL/min/1.73 m2.", + "The patient has claudication.", + "Bilateral claudication appeared 24 months prior.", + "The patient’s ankle brachial index was 0.75 on the right side.", + "The patient’s ankle brachial index was 0.56 on the left side.", + "Non-contrast MRA was chosen for the diagnosis.", + "Vascular ultrasound was chosen for the diagnosis.", + "Severe stenosis was detected at the bilateral common iliac artery to the external iliac artery on MRA.", + "Doppler echo on vascular ultrasound indicated that the culprit lesion was on the CIA and/or EIA on both sides.", + "Endovascular therapy was recommended.", + "The patient opted to proceed with zero-contrast EVT.", + "The patient had concurrent preparation for contrast administration." + ], + "summary": "We present the case of a 79-year-old man with bilateral claudication and advanced CKD. The patient had a high risk of sustained reduction in renal function and requirement of renal replacement therapy in the event that contrast media was used. Therefore, we planned a zero-contrast strategy for diagnosis and treatment. The case was diagnosed as bilateral stenotic iliac disease with non-contrast magnetic resonance angiography. Zero-contrast intervention was conducted successfully under magnetic resonance angiography and intra-vascular ultrasound guidance, resulting in an excellent clinical outcome and avoidance of worsening renal function.", + "summary_subclaims": [ + "The patient is a 79-year-old man.", + "The patient had bilateral claudication.", + "The patient had advanced CKD.", + "The patient had a high risk of sustained reduction in renal function.", + "The patient had a high risk of requirement of renal replacement therapy.", + "The risk was in the event that contrast media was used.", + "A zero-contrast strategy was planned for diagnosis and treatment.", + "The case was diagnosed as bilateral stenotic iliac disease.", + "Non-contrast magnetic resonance angiography was used for diagnosis.", + "Zero-contrast intervention was conducted.", + "The intervention was conducted under magnetic resonance angiography guidance.", + "The intervention was conducted under intra-vascular ultrasound guidance.", + "The intervention resulted in an excellent clinical outcome.", + "The intervention resulted in avoidance of worsening renal function." + ] + }, + { + "id": "multiclinsum_test_3227_en.txt", + "fulltext": "51-year-old woman with a 4-month history of recurrent episodes of oppressive precordial pain, dyspnoea and palpitations. She had coronary risk factors (hypertension, dyslipidaemia and smoking 15 packs/year), but no cardiovascular history. She was febrile (36 °C), with a blood pressure of 110/70 mmHg, heart rate of 72 bpm, respiratory rate of 16 bpm.\n\nThe cardiovascular examination was normal. The ECG revealed sinus rhythm and complete right bundle branch block. The two-dimensional transthoracic echocardiogram showed severe pericardial effusion surrounding the entire cardiac silhouette, without cardiac tamponade, and a round mass of 51 mm in diameter, heterogeneous, without flow inside it and without intracardiac protrusion. The magnetic resonance imaging (MRI) confirmed the solid, heterogeneous mass compromising the apex of both ventricles, 46 × 36 × 40 mm, compatible with a pericardial tumour. She evolved haemodynamically stable. A chest, abdominal and pelvic CT scan was performed, which did not show extra-cardiac compromise. The diagnostic coronary angiography did not show significant coronary lesions. The positron emission tomography with fluorodeoxyglucose-18 (PET-CT with FDG) ruled out extra-cardiac metastases. The tumour and the apex of both ventricles were surgically removed, with the placement of a pericardium patch. The resection was incomplete, because the tumour compromised the myocardium. The histological analysis with immunohistochemical techniques reported a primary synovial sarcoma of the pericardium with infiltration of the myocardium (vimentin +, EMA + and CD 99+) and the infiltration of the anterior wall of the right atrium presented an intracavitary protrusion (18 mm × 22 mm) and the infiltration of the interventricular septum showed a spherical mass protruding towards the left ventricle, 8 × 8 mm. The endomyocardial biopsy of the tumour was ruled out due to the risk of embolism and the poor surgical bed due to the history of previous surgery and radiotherapy. She received chemotherapy using liposomal doxorubicin and the echocardiogram at 9 months confirmed the complete resolution of the metastasis. She remained asymptomatic until 2 years later, when she died due to intestinal metastasis.\n", + "fulltext_subclaims": [ + "The patient is a 51-year-old woman.", + "She had a 4-month history of recurrent episodes of oppressive precordial pain, dyspnoea and palpitations.", + "She had coronary risk factors: hypertension, dyslipidaemia and smoking 15 packs/year.", + "She had no cardiovascular history.", + "She was febrile with a temperature of 36 °C.", + "The blood pressure was 110/70 mmHg.", + "The heart rate was 72 bpm.", + "The ECG revealed sinus rhythm.", + "The ECG revealed complete right bundle branch block.", + "The two-dimensional transthoracic echocardiogram showed severe pericardial effusion surrounding the entire cardiac silhouette.", + "The echocardiogram showed no cardiac tamponade.", + "The echocardiogram showed a round mass of 51 mm in diameter.", + "The mass was heterogeneous.", + "The mass had no flow inside it.", + "The mass had no intracardiac protrusion.", + "The MRI confirmed a solid, heterogeneous mass compromising the apex of both ventricles.", + "The mass measured 46 × 36 × 40 mm.", + "The mass was compatible with a pericardial tumour.", + "The patient evolved haemodynamically stable.", + "The chest, abdominal and pelvic CT scan did not show extra-cardiac compromise.", + "The diagnostic coronary angiography did not show significant coronary lesions.", + "The PET-CT with FDG ruled out extra-cardiac metastases.", + "The tumour and the apex of both ventricles were surgically removed.", + "A pericardium patch was placed.", + "The resection was incomplete because the tumour compromised the myocardium.", + "The histological analysis with immunohistochemical techniques reported a primary synovial sarcoma of the pericardium with infiltration of the myocardium.", + "The tumour infiltrated the anterior wall of the right atrium with an intracavitary protrusion of 18 mm × 22 mm.", + "The tumour infiltrated the interventricular septum with a spherical mass protruding towards the left ventricle, 8 × 8 mm.", + "The endomyocardial biopsy of the tumour was ruled out due to the risk of embolism.", + "The endomyocardial biopsy was ruled out due to the poor surgical bed from previous surgery and radiotherapy.", + "She received chemotherapy using liposomal doxorubicin.", + "The echocardiogram at 9 months confirmed complete resolution of the metastasis.", + "She remained asymptomatic until 2 years later.", + "She died due to intestinal metastasis." + ], + "summary": "We present the case of a 51-year-old patient who underwent incomplete surgical resection, chemotherapy and radiotherapy. To the best of our knowledge, this is the first case of a primary synovial sarcoma of the pericardium that remained asymptomatic for 5 years after surgery until a control CT scan detected cardiac metastases that compromised the right cavities. With chemotherapy, echocardiography demonstrated the complete resolution of the metastases.\n", + "summary_subclaims": [ + "The patient was 51 years old.", + "The patient underwent incomplete surgical resection.", + "The patient received chemotherapy.", + "The patient received radiotherapy.", + "This is the first case of a primary synovial sarcoma of the pericardium.", + "The tumor remained asymptomatic for 5 years after surgery.", + "A control CT scan detected cardiac metastases.", + "The metastases compromised the right cavities.", + "With chemotherapy, echocardiography demonstrated the complete resolution of the metastases." + ] + }, + { + "id": "multiclinsum_test_17_en.txt", + "fulltext": "A 58-year-old Caucasian male presented with acute kidney injury (AKI) and proteinuria in June 2016. He had originally been diagnosed with melanoma along the right flank in the 1980s that was treated with wide excisional removal. He was followed closely for over three decades with no signs of metastatic disease until he was noted to have a mass near his prior melanoma excisional scar in summer 2014. A biopsy at that time revealed an epithelioid neoplasm with morphology and phenotype highly suggestive of melanoma that was positive for the BRAF V600E mutation. A Positron Emission Tomography/Computed Tomography (PET/CT) at that time showed numerous bilateral pulmonary nodules, and a subsequent right upper lobe wedge resection did confirm metastatic melanoma. In May 2015, he was initiated on ipilimumab (3 mg/kg) and nivolumab (1 mg/kg) every 3 weeks for management of his metastatic melanoma. His course was complicated by grade 3 dermatitis, colitis, and hepatitis, which were treated with courses of prednisone. Therapy was ultimately discontinued in October 2015, after receiving a total of three cycles intermittently, as a result of worsening hepatitis confirmed by liver biopsy. Because of persistent bilateral lung metastases and left pleural metastases, the patient was initiated on dabrafenib 150 mg twice daily and trametinib 2 mg twice daily in December 2015, which he remained on until his presentation to nephrology in June of 2016. He had no personal or family history of chronic kidney disease (CKD). He denied exposure to nephrotoxic agents. He was only taking amlodipine 10 mg for hypertension and had been receiving immunotherapy with dabrafenib and trametinib since December 2015. He denied tobacco use, illicit drug use, and toxic environmental exposure. His blood pressure was 172/89 mm/Hg and had 2+ edema bilaterally. The remainder of his physical examination was normal, and laboratory results indicated a creatinine level of 2.4 mg/dL with a urinary protein-to-creatinine ratio of 2 g/g. His urinalysis showed dysmorphic erythrocytes and red blood cell casts. Renal ultrasonography was normal. Serologic testing was negative for Antineutrophil cytoplasmic autoantibody (ANCA), PR-3, Myeloperoxidase (MPO), and Anti-glomerular basement membrane (anti-GBM) antibody. Complement levels were normal. A renal biopsy was performed in September of 2016 showing focal crescentic (2 of 15 glomeruli with cellular crescents), proliferative, and sclerosing glomerulonephritis with diffuse linear staining of glomerular capillary loops dominant for IgG (3+), IgA (2+), kappa (2+), and lambda (1+) minimal changes . Ultrastructural examination of three glomeruli demonstrated areas with open capillary loops and preserved foot processes. Other areas demonstrated diffuse effacement of foot processes with variable thickening and wrinkling of glomerular basement membranes. No immune complex disease or tubuloreticular structures were identified.\nRepeat anti-GBM testing remained negative, and the patient’s creatinine eventually rose to a peak of 3.8’mg/dL. He had no signs or symptoms of lung hemorrhage. Dabrafenib and trametinib were discontinued, and he was subsequently initiated on oral cyclophosphamide (2 mg/kg/day) and pulse intravenous methylprednisolone (1000 mg daily for 3 consecutive days) followed by 1 mg/kg/day of prednisone. Serum creatinine improved to 2.5 mg/dL, and the active urinary sediment resolved. Immunosuppression with cyclophosphamide was discontinued after 4 months of therapy, and he was weaned off prednisone by 6 months.\nThe patient was off all immunotherapy for his malignancy, and his renal function remained relatively stable over the ensuing 12 months. By June 2018, a PET/CT of the chest showed evidence of metastatic melanoma to the left upper and medial lobes of the lung. The patient was placed back on nivolumab, which seemed to stabilize his oncologic disease. Unfortunately, 4 weeks after reinitiating nivolumab, his creatinine jumped from 2.8 to 5.8 mg/dL and home hemodialysis was initiated. The patient remains stable on home hemodialysis and was more recently taken off nivolumab and placed back on dabrafenib and trametinib for progressive metastatic pulmonary disease, which has led to significant symptom control.", + "fulltext_subclaims": [ + "The patient is a 58-year-old Caucasian male.", + "He presented with acute kidney injury (AKI) and proteinuria in June 2016.", + "He had been diagnosed with melanoma along the right flank in the 1980s.", + "The melanoma was treated with wide excisional removal.", + "He was followed closely for over three decades with no signs of metastatic disease.", + "In summer 2014, he was noted to have a mass near his prior melanoma excisional scar.", + "A biopsy at that time revealed an epithelioid neoplasm with morphology and phenotype highly suggestive of melanoma.", + "The biopsy was positive for the BRAF V600E mutation.", + "A PET/CT showed numerous bilateral pulmonary nodules.", + "A right upper lobe wedge resection confirmed metastatic melanoma.", + "In May 2015, he was initiated on ipilimumab (3 mg/kg) and nivolumab (1 mg/kg) every 3 weeks.", + "His course was complicated by grade 3 dermatitis, colitis, and hepatitis.", + "Therapy was discontinued in October 2015 after receiving a total of three cycles intermittently.", + "Therapy was discontinued due to worsening hepatitis confirmed by liver biopsy.", + "In December 2015, he was initiated on dabrafenib 150 mg twice daily and trametinib 2 mg twice daily.", + "He remained on dabrafenib and trametinib until his presentation to nephrology in June 2016.", + "He had no personal or family history of chronic kidney disease (CKD).", + "He denied exposure to nephrotoxic agents.", + "He was only taking amlodipine 10 mg for hypertension.", + "He had been receiving immunotherapy with dabrafenib and trametinib since December 2015.", + "He denied tobacco use, illicit drug use, and toxic environmental exposure.", + "His blood pressure was 172/89 mm/Hg.", + "He had 2+ edema bilaterally.", + "Laboratory results indicated a creatinine level of 2.4 mg/dL.", + "The urinary protein-to-creatinine ratio was 2 g/g.", + "Urinalysis showed dysmorphic erythrocytes and red blood cell casts.", + "Renal ultrasonography was normal.", + "Serologic testing was negative for ANCA, PR-3, MPO, and anti-GBM antibody.", + "Complement levels were normal.", + "A renal biopsy was performed in September of 2016.", + "The biopsy showed focal crescentic glomerulonephritis.", + "The biopsy showed proliferative and sclerosing glomerulonephritis.", + "The biopsy showed diffuse linear staining of glomerular capillary loops dominant for IgG (3+), IgA (2+), kappa (2+), and lambda (1+).", + "Ultrastructural examination showed areas with open capillary loops and preserved foot processes.", + "Other areas showed diffuse effacement of foot processes with variable thickening and wrinkling of glomerular basement membranes.", + "No immune complex disease or tubuloreticular structures were identified.", + "Repeat anti-GBM testing remained negative.", + "The patient’s creatinine eventually rose to a peak of 3.8 mg/dL.", + "He had no signs or symptoms of lung hemorrhage.", + "Dabrafenib and trametinib were discontinued.", + "He was initiated on oral cyclophosphamide (2 mg/kg/day) and pulse intravenous methylprednisolone (1000 mg daily for 3 consecutive days).", + "He was then started on 1 mg/kg/day of prednisone.", + "Serum creatinine improved to 2.5 mg/dL.", + "The active urinary sediment resolved.", + "Immunosuppression with cyclophosphamide was discontinued after 4 months of therapy.", + "He was weaned off prednisone by 6 months.", + "The patient was off all immunotherapy for his malignancy.", + "His renal function remained relatively stable over the ensuing 12 months.", + "By June 2018, a PET/CT showed evidence of metastatic melanoma to the left upper and medial lobes of the lung.", + "The patient was placed back on nivolumab.", + "Nivolumab seemed to stabilize his oncologic disease.", + "Four weeks after reinitiating nivolumab, his creatinine jumped from 2.8 to 5.8 mg/dL.", + "Home hemodialysis was initiated.", + "The patient remains stable on home hemodialysis.", + "He was more recently taken off nivolumab and placed back on dabrafenib and trametinib.", + "Dabrafenib and trametinib led to significant symptom control." + ], + "summary": "A 58-year-old Caucasian male was referred to our outpatient nephrology clinic with acute kidney injury and proteinuria. He had received three cycles of ipilimumab and nivolumab for recurrent melanoma positive for the BRAF V600E mutation with metastasis to the lungs. Immunotherapy had been discontinued in the setting of severe adverse effects including dermatitis, colitis, and hepatitis. Because of persistent bilateral lung metastases and left pleural metastases, the patient had been initiated on dabrafenib and trametinib until his presentation to our clinic 6 months later. On presentation, his blood pressure was 172/89 mm/Hg and had 2+ edema bilaterally. His creatinine level was 2.4 mg/dL from a previous normal baseline with a urinary protein-to-creatinine ratio of 2 g/g. His urinalysis showed dysmorphic erythrocytes and red blood cell casts. Serologic testing was negative for antineutrophilic cytoplasmic antibodies, proteinase 3 antigen, myeloperoxidase, and anti-glomerular basement membrane antibody. Complement levels were normal. A renal biopsy showed focal crescentic (2 of 15 glomeruli with cellular crescents), proliferative, and sclerosing glomerulonephritis with diffuse linear staining of glomerular capillary loops dominant for IgG (3+), IgA (2+), kappa (2+), and lambda (1+) minimal changes. He was initiated on oral cyclophosphamide and pulse intravenous methylprednisolone followed by oral prednisone for 6 months, which stabilized his renal function until reinitiation of immunotherapy.", + "summary_subclaims": [ + "The patient is a 58-year-old Caucasian male.", + "He was referred to an outpatient nephrology clinic with acute kidney injury and proteinuria.", + "He had received three cycles of ipilimumab and nivolumab for recurrent melanoma.", + "The melanoma was positive for the BRAF V600E mutation.", + "The melanoma had metastasis to the lungs.", + "Immunotherapy had been discontinued in the setting of severe adverse effects.", + "The patient had been initiated on dabrafenib and trametinib.", + "On presentation, his blood pressure was 172/89 mm/Hg.", + "He had 2+ edema bilaterally.", + "His creatinine level was 2.4 mg/dL.", + "His urinary protein-to-creatinine ratio was 2 g/g.", + "His urinalysis showed dysmorphic erythrocytes.", + "His urinalysis showed red blood cell casts.", + "Serologic testing was negative for antineutrophilic cytoplasmic antibodies.", + "Serologic testing was negative for proteinase 3 antigen.", + "Serologic testing was negative for myeloperoxidase.", + "Serologic testing was negative for anti-glomerular basement membrane antibody.", + "Complement levels were normal.", + "A renal biopsy showed focal crescentic glomerulonephritis.", + "A renal biopsy showed proliferative glomerulonephritis.", + "A renal biopsy showed sclerosing glomerulonephritis.", + "A renal biopsy showed diffuse linear staining of glomerular capillary loops dominant for IgG.", + "A renal biopsy showed diffuse linear staining of glomerular capillary loops with IgA.", + "A renal biopsy showed diffuse linear staining of glomerular capillary loops with kappa.", + "A renal biopsy showed diffuse linear staining of glomerular capillary loops with lambda.", + "He was initiated on oral cyclophosphamide.", + "He was initiated on pulse intravenous methylprednisolone.", + "He was initiated on oral prednisone.", + "The treatment was continued for 6 months.", + "The treatment stabilized his renal function.", + "The treatment was until reinitiation of immunotherapy." + ] + }, + { + "id": "multiclinsum_test_2382_en.txt", + "fulltext": "A 66-year-old Macedonian male presented with symptoms of constipation and blood in the stool (hematochezia) for 3–4 months before seeing a gastroenterologist. Review of his medical records revealed no family history of note. The outer anal examination revealed old thrombosed hemorrhoids, and endoscopy revealed an obstructive neoplastic mass located 5–7 cm from the anus. The tumor tissue showed diffuse ulcerations and bled when touched. Eight biopsy specimens were taken for pathohistological examination. The diagnosis of mucinous AC with signet ring cells was made. Radiographic examination showed no pathological findings in the liver, pancreas, spleen and lungs, but revealed a tumor mass in the left lower kidney pole with infiltrating border that caused compression to the collector system. Preoperative computed tomography confirmed synchronous tumors in the kidney and rectum . The patient was admitted to the University Clinic of Abdominal Surgery in Skopje for surgical treatment. Laboratory tests showed elevated values for the enzymes lactate dehydrogenase (612 U/L), alkaline phosphatase (387 U/L) and C-reactive protein (up to 45.7 mg/L). A medial laparotomy was performed, with surgical resection of the anterior rectal area, simultaneously with left nephrectomy. Carcinosis in the small pelvis was observed.\nTissue samples were analyzed at the Institute of pathology, Faculty of Medicine in Skopje. Gross rectal examination of tissue specimens showed a rectal tumor measuring 5.5 cm infiltrating into the perirectal fat. The kidney contained a yellowish round tumor measuring 5 cm, with necrosis and hemorrhage. The adrenal gland was slightly enlarged into perirenal fat. The tissue specimens were fixed in formalin, embedded in Paraffin and routinely stained with hematoxylin & eosin stain. Microscopic analysis revealed PSRCCR with nodal metastasis, lymphatic and vascular tumor emboli and uncommon metastasis to synchronous RCC and to the adrenal gland . The tumor was classified as Stage IV according to the pTNM/UICC staging system. All specimens were analyzed immunohistochemicaly with CK20, CDX2, vimentin, RCC, E-cadherin and the mismatch repair (MMR) proteins MLH1, MSH2, MSH6 and PMS2. Signet ring cells were positive for CDX2 and CK20 . The absence of expression of E-cadherin in the metastasized cells indicated that they were the same as those in the primary carcinoma .\nThere was nuclear expression only of MMR protein MSH6, whereas the MMR proteins MLH1, MSH2 and PMS2 showed loss of the nuclear signal . Therefore, the tumor was further analyzed molecularly using the ABI 310 DNA analyzer (Applied Biosystems, Foster City, CA, USA), which revealed a microsatellite stable (MSS) tumor. Molecular analysis showed mutations in TP53 and ERBB2, as determined by next-generation sequencing of AKT1, BRAF, EGFR, ERBB2, FOXL2, GNA11, GNAQ, KIT, KRAS, MET, NRAS, PDGFRA, PIK3CA, RET and TP53. The patient died a few months after surgical treatment.", + "fulltext_subclaims": [ + "The patient is a 66-year-old Macedonian male.", + "He had symptoms of constipation and blood in the stool for 3–4 months.", + "The outer anal examination revealed old thrombosed hemorrhoids.", + "Endoscopy revealed an obstructive neoplastic mass located 5–7 cm from the anus.", + "The tumor tissue showed diffuse ulcerations and bled when touched.", + "Eight biopsy specimens were taken for pathohistological examination.", + "The diagnosis of mucinous AC with signet ring cells was made.", + "Radiographic examination showed a tumor mass in the left lower kidney pole.", + "Preoperative computed tomography confirmed synchronous tumors in the kidney and rectum.", + "The patient was admitted to the University Clinic of Abdominal Surgery in Skopje.", + "A medial laparotomy was performed.", + "Surgical resection of the anterior rectal area was performed.", + "Left nephrectomy was performed.", + "Carcinosis in the small pelvis was observed.", + "Gross rectal examination showed a rectal tumor measuring 5.5 cm.", + "The rectal tumor infiltrated into the perirectal fat.", + "The kidney tumor measured 5 cm.", + "The kidney tumor showed necrosis and hemorrhage.", + "The adrenal gland was slightly enlarged into perirenal fat.", + "Tissue specimens were fixed in formalin.", + "Tissue specimens were embedded in Paraffin.", + "Tissue specimens were stained with hematoxylin & eosin.", + "Microscopic analysis revealed PSRCCR with nodal metastasis.", + "Lymphatic and vascular tumor emboli were observed.", + "Uncommon metastasis to synchronous RCC and the adrenal gland was observed.", + "The tumor was classified as Stage IV according to the pTNM/UICC staging system.", + "Tissue specimens were analyzed immunohistochemically with CK20, CDX2, vimentin, RCC, E-cadherin, and MMR proteins.", + "Signet ring cells were positive for CDX2.", + "Signet ring cells were positive for CK20.", + "The absence of expression of E-cadherin in the metastasized cells indicated they were the same as those in the primary carcinoma.", + "There was nuclear expression only of MMR protein MSH6.", + "MMR proteins MLH1, MSH2, and PMS2 showed loss of the nuclear signal.", + "The tumor was analyzed molecularly using the ABI 310 DNA analyzer.", + "The tumor was microsatellite stable (MSS).", + "Molecular analysis showed mutations in TP53 and ERBB2.", + "The patient died a few months after surgical treatment." + ], + "summary": "We present the case of a 66-year-old Macedonian man with synchronous rectal signet ring cell carcinoma and RCC with tumor to tumor metastasis feature. He underwent a left nephrectomy and anterior rectal resection after complaining of constipation for 3-4 months and the appearance of synchronous tumors on the imaging studies. Morphology and immunohistochemical analysis of specimens from the RCC revealed signet ring cells identical to the rectal signet ring cell carcinoma. The next-generation sequencing study revealed mutations in TP53 and ERBB2, and microsatellite stable signet ring cell carcinoma was determined by deoxyribonucleic acid (DNA) sequencing.", + "summary_subclaims": [ + "The patient is a 66-year-old Macedonian man.", + "The patient had synchronous rectal signet ring cell carcinoma and RCC.", + "The tumors showed tumor to tumor metastasis.", + "The patient underwent a left nephrectomy.", + "The patient underwent anterior rectal resection.", + "The patient had complained of constipation for 3-4 months.", + "Synchronous tumors were seen on imaging studies.", + "Morphology of the RCC specimens revealed signet ring cells.", + "Immunohistochemical analysis showed signet ring cells identical to the rectal signet ring cell carcinoma.", + "Next-generation sequencing revealed mutations in TP53.", + "Next-generation sequencing revealed mutations in ERBB2.", + "Microsatellite stable signet ring cell carcinoma was determined by DNA sequencing." + ] + }, + { + "id": "multiclinsum_test_136_en.txt", + "fulltext": "A 3-year-old girl was transferred to our center for severe cough, shortness of breath, fatigue and fever. Physical examination revealed facial deformities and growth retardation. The patient was diagnosed with hypothyroidism, CHD and PH by examinations at the age of 11 months old. Her transcutaneous finger oxygen saturation was 70%. Echocardiography showed a 0.9cm-wide ASD, a widened pulmonary artery, and severe tricuspid regurgitation . Laboratory tests suggested that NT-proBNP was 3907pg/ml, the C-reaction protein level was 19.83mg/L, and the white blood cell was in the normal range, but the percentage of neutrophils increased to 78.7%, and (respiratory syncytial virus) RSV-IgM was positive. Liver function, kidney function, the level of autoimmune antibodies, and the erythrocyte sedimentation rate were normal. The patient was given anti-infection and cardiotonic drugs as well as respiratory support after admission.\nMeanwhile, the patient underwent right heart catheterization. The results indicated that the mean pulmonary arterial pressure (mPAP, 71mmHg) was markedly increased, the pulmonary vascular resistance (PVR, 27WU) also enlarged, and the pulmonary capillary wedge pressure (PCWP) is normal. Since the ASD was small and the slow flow rate could not result in the tremendous elevation in the pulmonary arterial pressure, the pathogenesis should be further investigated. No obvious abnormalities were found from the results of the pulmonary test, cardiac CTA and other routine etiological examinations in the patient. Nevertheless, the genetic inspection (the accession number for the whole-exome sequencing data is HRA005032) showed that the patient had a KMT2D (ENSMBL reference ID: NM_003482.3) exon 39 c.12209_12210del p.(Ser4070fs) mutation . Based on the genetic results and abnormal countenance, the patient was diagnosed with KS type 1. The patient developed severe PH and poor oxygenation, and she was classified into the high-risk population by risk stratification was. Therefore, she received triple targeted pulmonary vascular pressure reduction treatment, i.e., Ambrisentan (2.5mg once daily) + Tadalafil (10mg once daily) + Remodulin (continuous subcutaneous pumping). The patient was followed up regularly after discharge, but the effect was unsatisfactory. The latest echocardiography reexamination showed no change in the size of the ASD, moderate tricuspid regurgitation, and estimated pulmonary arterial systolic pressure of 96mmHg.", + "fulltext_subclaims": [ + "The patient is a 3-year-old girl.", + "The patient had severe cough.", + "The patient had shortness of breath.", + "The patient had fatigue.", + "The patient had fever.", + "Physical examination revealed facial deformities.", + "Physical examination revealed growth retardation.", + "The patient was diagnosed with hypothyroidism at the age of 11 months.", + "The patient was diagnosed with CHD at the age of 11 months.", + "The patient was diagnosed with PH at the age of 11 months.", + "The patient's transcutaneous finger oxygen saturation was 70%.", + "Echocardiography showed a 0.9cm-wide ASD.", + "Echocardiography showed a widened pulmonary artery.", + "Echocardiography showed severe tricuspid regurgitation.", + "NT-proBNP was 3907pg/ml.", + "C-reaction protein level was 19.83mg/L.", + "The percentage of neutrophils increased to 78.7%.", + "RSV-IgM was positive.", + "The patient was given anti-infection drugs.", + "The patient was given cardiotonic drugs.", + "The patient received respiratory support.", + "The patient underwent right heart catheterization.", + "The mean pulmonary arterial pressure was 71mmHg.", + "The pulmonary vascular resistance was 27WU.", + "The pulmonary capillary wedge pressure was normal.", + "The ASD was small.", + "The slow flow rate could not result in the tremendous elevation in the pulmonary arterial pressure.", + "No obvious abnormalities were found from the results of the pulmonary test.", + "No obvious abnormalities were found from the results of the cardiac CTA.", + "The genetic inspection showed that the patient had a KMT2D exon 39 c.12209_12210del p.(Ser4070fs) mutation.", + "The patient was diagnosed with KS type 1.", + "The patient developed severe PH.", + "The patient was classified into the high-risk population by risk stratification.", + "The patient received triple targeted pulmonary vascular pressure reduction treatment.", + "The patient received Ambrisentan (2.5mg once daily).", + "The patient received Tadalafil (10mg once daily).", + "The patient received Remodulin (continuous subcutaneous pumping).", + "The patient was followed up regularly after discharge.", + "The effect of treatment was unsatisfactory.", + "The latest echocardiography reexamination showed no change in the size of the ASD.", + "The latest echocardiography reexamination showed moderate tricuspid regurgitation.", + "The latest echocardiography reexamination showed an estimated pulmonary arterial systolic pressure of 96mmHg." + ], + "summary": "A 3-year-old girl was transferred to our center for severe cough, shortness of breath, fatigue and fever. Physical examination revealed facial deformities and growth retardation. Echocardiography showed a small atrial septal defect (ASD), and right heart catheterization indicated a significant increase in pulmonary vascular pressure and resistance. The genetic test suggested that she had a KMT2D gene mutation. The patient was finally diagnosed with KS. She was given targeted drugs to reduce pulmonary vascular pressure, but the effect was unsatisfactory.", + "summary_subclaims": [ + "The patient is a 3-year-old girl.", + "She was transferred to our center.", + "She had severe cough.", + "She had shortness of breath.", + "She had fatigue.", + "She had fever.", + "Physical examination revealed facial deformities.", + "Physical examination revealed growth retardation.", + "Echocardiography showed a small atrial septal defect.", + "Right heart catheterization indicated a significant increase in pulmonary vascular pressure.", + "Right heart catheterization indicated a significant increase in pulmonary vascular resistance.", + "The genetic test suggested that she had a KMT2D gene mutation.", + "The patient was finally diagnosed with KS.", + "She was given targeted drugs to reduce pulmonary vascular pressure.", + "The effect of the targeted drugs was unsatisfactory." + ] + }, + { + "id": "multiclinsum_test_2748_en.txt", + "fulltext": "A 42-year-old white man without pre-existing comorbidities was transferred to our unit on 8 September 2014. He was involved in a car crash on 30 August 2014 with traumatic hemorrhagic shock and an ISS of 28. Shock resuscitation according to Advanced Trauma Life Support (ATLS) guidelines and massive transfusion policy were immediately started . Upon hemodynamic stabilization, a total body computed tomography (CT) scan confirmed unstable pelvic fractures and right flank mesenteric bleeding, without clear evidence of intestinal perforation. Damage control surgery of his pelvic fractures was performed by positioning external fixators [, ]. Transfer to our unit was then planned for definitive osteosynthesis.\nOn arrival he had fever and profuse diarrhea, leukocytosis, normal procalcitonin (PCT), elevated C-reactive protein (CRP), lactate 0.9 mmol/L, an Acute Physiology and Chronic Health Evaluation (APACHE) II score of 11, and a Sequential Organ Failure Assessment (SOFA) score of 3; his Predisposition, Infection, Response, and Organ Dysfunction (PIRO) score was 5 . He wore a tracheostomy and was mechanically ventilated on analgosedation; he was left on parenteral nutrition and a minimal enteral feeding was started.\nChest X-rays detected a right basal infiltrate. Orthopedic surgery was postponed. After thorough microbiological sampling, immune chromatography for Clostridium difficile was negative, rectal swabs grew MDR Acinetobacter baumannii, whereas blood cultures yielded coagulase-negative staphylococci. His antibiotic therapy was modified as described here and in Table . As external fixators poured purulent secretions, on day 15 he underwent definitive pelvic osteosynthesis in spite of persistent fever and diarrhea . Septic shock ensued 24 hours after surgery, with oliguria, leukocytosis, PCT 4.39 ng/ml, CRP 46.6 mg/L, and lactate 1.17 mmol/L; his SOFA score rose to 6. After adequate fluid resuscitation, norepinephrine was added for persistent hypotension, based on data of hemodynamic monitoring (cardiac output and stroke volume variation using PiCCO Plus monitoring system) and trends of central venous saturation of oxygen (ScVO2). Low doses of steroids were prescribed for the first 3 days. Microbiological sampling included blood cultures, quantitative culture of tracheal secretions, and culture of urine . Blood cultures were negative; urine and tracheal aspirate samples were positive for CRKP and MDR A. baumannii.\nHe had a short-lasting improvement, with fever, abdominal pain, and vomiting relapsing after a few days; a repeated CT scan of his abdomen revealed suprapubic and left ischiatic abscesses at surgical sites, as well as dilated bowel due to paralytic ileus. Surgical debridement was performed, followed by vacuum-assisted closure (VAC) therapy . Intraoperative microbiological sampling revealed multiple CRKP isolates, with a worsened resistance profile, including colimycin (colistin) resistance. He improved and a control radiographic (RX) scan of his thorax was negative; bronchoalveolar lavage (BAL) sampling, however, confirmed persistence at low bacterial load of CRKP. After 21 days, colimycin was withdrawn. However, 4 days later, he had fever and severe leukocytosis; he relapsed with acute renal failure: creatinine 2.53 mg/dL and acute kidney injury (AKI) stage 2 according to the Kidney Disease: Improving Global Outcomes classification (KDIGO) . His PCT levels rose above 100 ng/ml, his lactate was 3.3 mmol/L, and his SOFA score was 10. After further blood sampling for blood cultures and multiplex polymerase chain reaction (PCR; Magicplex™ Sepsis Test, Seegene), colimycin and anidulafungin were restarted with the addition of rifampicin . Multiplex PCR revealed A. baumannii and Candida albicans. To support septic shock recovery, two extracorporeal hemoperfusion devices were used: the Polymyxin B-Immobilized Cartridge (Toraymyxin® PMX 20-R, Toray Medical, Tokyo, Japan), allowing endotoxin removal and coupled plasma filtration adsorption (CPFA; CPFA® LYNDA®, Bellco, Mirandola, Italy), a hydrophobic resin with high affinity for many inflammatory mediators. Within 3 days, two Polymyxin B and three CPFA treatments were overall delivered. Clinical improvement ensued; his PCT fell to 19.25 ng/ml and serum creatinine to 1.82 mg/dL. Microbiological samples yielded: MDR A. baumannii and CRKP from tracheal aspirate, C. albicans and MDR A. baumannii from blood cultures, and A. baumannii and panresistant CRKP from wound swabs. In spite of septic shock reversal, he remained febrile with diarrhea and worsening anemia in the next 2 weeks. Control blood cultures (three lots) were persistently positive for C. Albicans, A. baumannii and CRKP. Ophthalmoscopy revealed retinal involvement, so that sequential therapy with liposomal amphotericin B was started. In the following weeks frequent vomiting ensued, impeding any enteral nutrition; his abdominal pain increased, paralleled by a palpable mass in his right flank. Colonoscopy revealed patchy serpiginous ulcers; a repeated CT of his abdomen revealed a periappendicular mass. Based on such data, after repeated multidisciplinary consults, an exploratory laparotomy was at last performed and an inflammatory pseudotumor of his right colon was diagnosed and resected with ileostomy. Soon after surgery, his blood cultures turned negative. Colimycin was interrupted. Once more, septic shock relapsed 4 days later. Leukocytosis, hypotension, PCT >100 ng/mL, renal failure, and lactate 4.0 mmol/L led to a SOFA score of 11; creatinine zenith was 4.73 mg/dL. Combination antibiotic therapy was modified (see Table ) and a single Polymyxin B extracorporeal hemoperfusion cycle was repeated. Blood cultures were persistently positive for CRKP. After interdisciplinary consultation, removal of pelvic synthesis media was anticipated. Shortly after surgery, he improved; 3 weeks later, microbiological and biochemical evidence of infection resolved, as well as gastric atonia. Combination therapy was continued for 56 days . He was transferred to the orthopedic ward after 146 days of ICU stay and later to rehabilitation. At present, he is doing well at home able to walk.", + "fulltext_subclaims": [ + "The patient is a 42-year-old white man.", + "He had no pre-existing comorbidities.", + "He was transferred to the unit on 8 September 2014.", + "He was involved in a car crash on 30 August 2014.", + "He had traumatic hemorrhagic shock.", + "He had an ISS of 28.", + "Shock resuscitation was started according to ATLS guidelines.", + "A massive transfusion policy was initiated.", + "A total body CT scan confirmed unstable pelvic fractures.", + "The CT scan showed right flank mesenteric bleeding.", + "There was no clear evidence of intestinal perforation.", + "Damage control surgery was performed by positioning external fixators.", + "Transfer to the unit was planned for definitive osteosynthesis.", + "On arrival, he had fever.", + "On arrival, he had profuse diarrhea.", + "On arrival, he had leukocytosis.", + "On arrival, his procalcitonin was normal.", + "On arrival, his C-reactive protein was elevated.", + "On arrival, his lactate was 0.9 mmol/L.", + "His APACHE II score was 11.", + "His SOFA score was 3.", + "His PIRO score was 5.", + "He wore a tracheostomy.", + "He was mechanically ventilated on analgosedation.", + "He was on parenteral nutrition.", + "A minimal enteral feeding was started.", + "Chest X-rays detected a right basal infiltrate.", + "Orthopedic surgery was postponed.", + "Immune chromatography for Clostridium difficile was negative.", + "Rectal swabs grew MDR Acinetobacter baumannii.", + "Blood cultures yielded coagulase-negative staphylococci.", + "His antibiotic therapy was modified.", + "External fixators poured purulent secretions.", + "On day 15, he underwent definitive pelvic osteosynthesis.", + "This was despite persistent fever and diarrhea.", + "Septic shock ensued 24 hours after surgery.", + "He had oliguria.", + "His PCT was 4.39 ng/ml.", + "His CRP was 46.6 mg/L.", + "His lactate was 1.17 mmol/L.", + "His SOFA score rose to 6.", + "Norepinephrine was added for persistent hypotension.", + "Low doses of steroids were prescribed for the first 3 days.", + "Blood cultures were negative.", + "Urine and tracheal aspirate samples were positive for CRKP and MDR A. baumannii.", + "A repeated CT scan of the abdomen revealed suprapubic and left ischiatic abscesses.", + "Surgical debridement was performed.", + "VAC therapy was used.", + "Intraoperative microbiological sampling revealed multiple CRKP isolates.", + "These isolates had a worsened resistance profile, including colistin resistance.", + "A control radiographic scan of the thorax was negative.", + "Bronchoalveolar lavage sampling confirmed persistence at low bacterial load of CRKP.", + "After 21 days, colistin was withdrawn.", + "Four days later, he had fever and severe leukocytosis.", + "He relapsed with acute kidney injury stage 2 according to KDIGO.", + "His PCT levels rose above 100 ng/ml.", + "His lactate was 3.3 mmol/L.", + "His SOFA score was 10.", + "Colistin and anidulafungin were restarted with the addition of rifampicin.", + "Multiplex PCR revealed A. baumannii and Candida albicans.", + "Two extracorporeal hemoperfusion devices were used.", + "Two Polymyxin B and three CPFA treatments were delivered.", + "His PCT fell to 19.25 ng/ml.", + "His serum creatinine fell to 1.82 mg/dL.", + "Microbiological samples yielded MDR A. baumannii and CRKP from tracheal aspirate.", + "Microbiological samples yielded C. albicans and MDR A. baumannii from blood cultures.", + "Microbiological samples yielded A. baumannii and panresistant CRKP from wound swabs.", + "Ophthalmoscopy revealed retinal involvement.", + "Sequential therapy with liposomal amphotericin B was started.", + "Colonoscopy revealed patchy serpiginous ulcers.", + "A repeated CT of the abdomen revealed a periappendicular mass.", + "An exploratory laparotomy was performed.", + "An inflammatory pseudotumor of the right colon was diagnosed.", + "It was resected with ileostomy.", + "Soon after surgery, his blood cultures turned negative.", + "Colistin was interrupted.", + "Septic shock relapsed 4 days later.", + "His SOFA score was 11.", + "His creatinine zenith was 4.73 mg/dL.", + "A single Polymyxin B extracorporeal hemoperfusion cycle was repeated.", + "Blood cultures were persistently positive for CRKP.", + "Removal of pelvic synthesis media was anticipated.", + "Shorty after surgery, he improved.", + "Three weeks later, microbiological and biochemical evidence of infection resolved.", + "Combination therapy was continued for 56 days.", + "He was transferred to the orthopedic ward after 146 days of ICU stay.", + "He was later transferred to rehabilitation.", + "At present, he is doing well at home.", + "He is able to walk." + ], + "summary": "A 42-year-old white man presented with traumatic hemorrhagic shock. Unstable pelvic fractures led to emergency stabilization surgery. Fever ensued with diarrhea, followed by septic shock. Two weeks later, an abdominal computed tomography scan revealed suprapubic and ischiatic abscesses at surgical sites, as well as dilated bowel. Debridement of both surgical sites, performed with vacuum-assisted closure therapy, yielded isolates of carbapenem and colistin-resistant Klebsiella pneumoniae. Antibiotic treatment was de-escalated after 21 days; 4 days later fever, leukocytosis, hypotension and acute renal failure relapsed. Blood purification techniques were started, for the removal of endotoxin and inflammatory mediators, with sequential hemodialysis. Clinical improvement ensued; blood cultures yielded Candida albicans and multidrug-resistant Acinetobacter baumannii; panresistant carbapenemase-producing Klebsiella pneumoniae grew from wound swabs. In spite of shock reversal, our patient remained febrile, with diarrhea. Control blood cultures yielded Candida albicans, Acinetobacter baumannii and carbapenem-resistant Klebsiella pneumoniae. His abdominal pain increased, paralleled by a right flank palpable mass. Colonoscopy revealed patchy serpiginous ulcers. At exploratory laparotomy, an inflammatory post-traumatic pseudotumor of his right colon was removed. Blood cultures turned negative after surgery. Septic shock, however, relapsed 4 days later. A blood purification cycle was repeated and combination antimicrobial therapy continued. Surgical wounds and blood cultures were persistently positive for carbapenem-resistant Klebsiella pneumoniae. Removal of pelvic synthesis media was therefore anticipated. Three weeks later, clinical, microbiological, and biochemical evidence of infection resolved.", + "summary_subclaims": [ + "The patient is a 42-year-old white man.", + "He presented with traumatic hemorrhagic shock.", + "Unstable pelvic fractures led to emergency stabilization surgery.", + "Fever ensued with diarrhea.", + "Two weeks later, an abdominal computed tomography scan revealed suprapubic and ischiatic abscesses at surgical sites.", + "Debridement of both surgical sites was performed with vacuum-assisted closure therapy.", + "Isolates of carbapenem and colistin-resistant Klebsiella pneumoniae were obtained.", + "Antibiotic treatment was de-escalated after 21 days.", + "Four days after de-escalation, fever, leukocytosis, hypotension, and acute renal failure relapsed.", + "Blood purification techniques were started for the removal of endotoxin and inflammatory mediators.", + "Sequential hemodialysis was used.", + "Clinical improvement ensued.", + "Blood cultures yielded Candida albicans and multidrug-resistant Acinetobacter baumannii.", + "Panresistant carbapenemase-producing Klebsiella pneumoniae grew from wound swabs.", + "The patient remained febrile with diarrhea.", + "Control blood cultures yielded Candida albicans, Acinetobacter baumannii, and carbapenem-resistant Klebsiella pneumoniae.", + "Colonoscopy revealed patchy serpiginous ulcers.", + "An inflammatory post-traumatic pseudotumor of the right colon was removed at exploratory laparotomy.", + "Blood cultures turned negative after surgery.", + "Septic shock relapsed 4 days later.", + "A blood purification cycle was repeated.", + "Combination antimicrobial therapy was continued.", + "Surgical wounds and blood cultures were persistently positive for carbapenem-resistant Klebsiella pneumoniae.", + "Removal of pelvic synthesis media was therefore anticipated.", + "Three weeks later, clinical, microbiological, and biochemical evidence of infection resolved." + ] + }, + { + "id": "multiclinsum_test_1069_en.txt", + "fulltext": "A 9-year-old boy (14 kg) was admitted with feeding difficulties after birth caused by spastic CP.\nAfter birth, the patient had persistent feeding difficulties, accompanied by repeated coughing and vomiting after eating. He was diagnosed with spastic CP along with severe malnutrition, thoracic scoliosis, laryngomalacia, pneumonia, and multiple site deformities, including those of the airway, thorax, hip joint, and both hands and feet. In addition to epilepsy and taking clonazepam 1 mg, phenobarbital 25 mg, levetiracetam 150 mg, and sodium valproate oral liquid 5 mL twice daily, he had a history of aspiration pneumonia and copious purulent sputum, for which he was prescribed antibiotics for 9 d. He was scheduled to undergo implantation of an implantable venous access port and gastrostomy to improve feeding and nutrition. This was not a typical elective operation and was difficult to adjust to a conventionally safe state, because the pneumonia was protracted and nursing conditions were limited.\nThe patient was diagnosed with spastic CP along with severe malnutrition, thoracic scoliosis, laryngomalacia, pneumonia, and multiple site deformities, including those of the airway, thorax, hip joint, and both hands and feet.\nThe patient had been abandoned as a toddler, and his birth and family histories were uncertain.\nThe patient’s general physical examination revealed typical facial dysmorphism, thoracic deformities, scoliosis, oxycephaly, and hip dislocation. He showed a Mallampati class IV airway with severely limited neck movement, thyromental distance of fewer than three fingers, and 20-mm-inter-incisor distance. Auscultation indicated an obvious UAO with distinct sputum sounds, and oxygen saturation (SpO2) was 85%-90% on 3 L/min of supplemental oxygen using a nasal oxygen cannula. Preoperative evaluation exhibited a class III physical status of American Society of Anesthesiologists with a difficult airway.\nRoutine blood tests showed a hemoglobin (Hb) level of 9.7 g/dL, hematocrit of 33.3%, mean corpuscular volume of 73.9 fL, mean corpuscular Hb of 21.6 pg, and mean corpuscular Hb concentration of 29.2 g/dL. Other blood test results showed no significant abnormalities.\nChest radiography demonstrated pneumonia, scoliosis, and right deviation of the trachea . Computed tomography (CT) scans revealed scoliosis, osteoporosis of the spine, significant atrophy of the muscles of the back in the bilateral thoracolumbar region with fat infiltration, and thoracic and tracheal malformation . Lateral cervical spine CT scans displayed laryngomalacia and malformations of the pharynx and cervical spine .", + "fulltext_subclaims": [ + "The patient is a 9-year-old boy weighing 14 kg.", + "The patient had feeding difficulties after birth.", + "The patient was diagnosed with spastic CP.", + "The patient had repeated coughing and vomiting after eating.", + "The patient was diagnosed with severe malnutrition.", + "The patient had thoracic scoliosis.", + "The patient had laryngomalacia.", + "The patient had pneumonia.", + "The patient had multiple site deformities, including those of the airway, thorax, hip joint, and both hands and feet.", + "The patient had a history of aspiration pneumonia.", + "The patient had copious purulent sputum.", + "The patient was prescribed antibiotics for 9 days.", + "The patient was scheduled to undergo implantation of an implantable venous access port.", + "The patient was scheduled to undergo gastrostomy.", + "The patient had a Mallampati class IV airway.", + "The patient had a thyromental distance of fewer than three fingers.", + "The patient's oxygen saturation was 85%-90% on 3 L/min of supplemental oxygen.", + "The patient was classified as American Society of Anesthesiologists class III.", + "The patient had a difficult airway.", + "Chest radiography demonstrated pneumonia.", + "Chest radiography demonstrated scoliosis.", + "Chest radiography demonstrated right deviation of the trachea.", + "Computed tomography scans revealed scoliosis.", + "Computed tomography scans revealed osteoporosis of the spine.", + "Computed tomography scans revealed significant atrophy of the muscles of the back in the bilateral thoracolumbar region with fat infiltration.", + "Computed tomography scans revealed thoracic and tracheal malformation.", + "Lateral cervical spine CT scans displayed laryngomalacia.", + "Lateral cervical spine CT scans displayed malformations of the pharynx and cervical spine." + ], + "summary": "A 9-year-old boy with spastic cerebral palsy, severe malnutrition, thoracic scoliosis, thoracic and airway malformation, laryngomalacia, pneumonia, and epilepsy faced the risk of anesthesia during palliative surgery. After a thorough preoperative evaluation, a detailed scheme for anesthesia and a series of intubation tools were prepared by a team of anesthesiologists. Awake fiberoptic intubation is the widely accepted strategy for patients with anticipated difficult airways. Given the age and medical condition of the patient, we kept him sedated with spontaneous breathing during endotracheal intubation. The endotracheal intubation was completed on the second attempt after the failure of the first effort. Fortunately, the surgery was successful without postoperative complications.", + "summary_subclaims": [ + "The patient is a 9-year-old boy.", + "The patient has spastic cerebral palsy.", + "The patient has severe malnutrition.", + "The patient has thoracic scoliosis.", + "The patient has thoracic and airway malformation.", + "The patient has laryngomalacia.", + "The patient has pneumonia.", + "The patient has epilepsy.", + "The patient faced the risk of anesthesia during palliative surgery.", + "A preoperative evaluation was performed.", + "A detailed scheme for anesthesia was prepared.", + "A series of intubation tools were prepared.", + "Awake fiberoptic intubation is the widely accepted strategy for patients with anticipated difficult airways.", + "The patient was sedated with spontaneous breathing during endotracheal intubation.", + "The endotracheal intubation was completed on the second attempt.", + "The first intubation effort failed.", + "The surgery was successful.", + "There were no postoperative complications." + ] + }, + { + "id": "multiclinsum_test_951_en.txt", + "fulltext": "A 41-year-old Caucasian woman was admitted at the hospital with one-month history of asthenia, anorexia, fever, abdominal pain, early postprandial surfeit, and diarrhea. She had past history of an intermittent migratory pruritic maculopapular rash and mild episodes of flushing that had never been investigated, hypothyroidism, an anxiety disorder, and emotional instability, and she had smoked 20 cigarettes a day since the age of 13. There was no history of allergies or other pathologies.\nWhen first observed at the hospital, she had a fever, a dark spot on the tongue, a slightly pruritic brownish erythematous maculopapular skin rash predominantly in the upper limbs, hepatomegaly (the left lobe of liver was enlarged and extended to epigastric region and the right lobe was four fingers below the right costal margin in the midclavicular line), and splenomegaly (5 fingers below the left costal margin). There was no peripheral lymphadenopathy.\nPeripheral blood counts revealed pancytopenia: hemoglobin (Hg) 11.0 g/dl (normal range 12.0–15.0), platelets 16 × 109/L (normal range 150–400), and white blood cells (WBC) 4.25 × 109/L (normal range 4.0–11.0) with 7.0% neutrophils (0.3 × 109/L) (normal range 2.0–7.5), 6% blast cells (BC), and 20% of cells with metachromatic cytoplasmic granules that were initially classified as basophils by morphology , but whose immunophenotypic study subsequently revealed them to be an abnormal immature MC.\nSerum biochemistry showed elevated lactate dehydrogenase (369 U/L, normal range 135–214 U/L) and abnormal hepatic tests with a cholestatic pattern: total bilirubin 1.2 mg/dl (normal range: 0.2–1.0), direct bilirubin 1.1 mg/dl (normal range: 0.0–0.2), indirect bilirubin 1.14 mg/dl (normal range: 0.0–1.0), alanine transaminase 90 U/L (normal range: 10–30), aspartate transaminase 36 U/L (normal range: 10–30), alkaline phosphatase 731 U/L (normal range: 32–104), and gamma-glutamyl transferase 638 U/L (normal range: 6–39). There was also hypoalbuminemia (serum albumin 32 g/L, normal range: 35–50) and hypogammaglobulinemia (serum IgG 522 mg/dl, normal range: 793–1590; IgA 127 mg/dl, normal range: 114–457; IgM 170 mg/dl, normal range: 29–226). Serum tryptase levels were markedly increased (184 μg/L, normal range < 13 μg/L). Calcium and phosphate serum levels were normal, as did renal function tests. Coagulation tests, including prothrombin time, activated partial thromboplastin time, and fibrinogen levels, were within the normal range. Serological tests for hepatitis B and C viruses and human immunodeficiency virus type 1 and 2 were negative.\nBone marrow smears showed 24% myeloperoxidase (MPO) positive BC, 17% promyelocytes, 4% myelocytes, 3% metamyelocytes + neutrophils (AML-M2 classification by cytomorphology), 30% erythroid lineage, and 16% morphologically abnormal toluidine blue positive MC . These cells had variable morphological features, from atypical MC type I and II to metachromatic blasts. There was no BM eosinophilia, or evidence of myelodysplasia. Flow cytometry of the BM aspirate revealed 12% of CD45+ (low), CD117+, CD34+ myeloid precursor cells (MPC) also expressing CD123, HLA-DR (high), CD13, CD33, CD65 (low), and CD25 (low, in part of the cells) but lacking CD10, CD15, CD16, CD2, CD30, and FcεRI/IgE; 5% of CD45+ (low), CD117+, CD34− MC precursors (MCP), also being positive for CD123 (high), CD13, CD33, CD65 (low), CD25, CD30, FcεRI/IgE, and HLA-DR (high), and lacking CD10, CD15, CD16, and CD2; 34% promyelocytes with an aberrant phenotype (CD45+, CD34−, CD117+, CD13+low, CD33+, CD65+; CD15+, MPO+, and CD2, CD10, CD11b, CD16, CD25, CD30, FcεRI/IgE, and HLA-DR negative); a maturation blockage at the promyelocyte level, as revealed by an abnormal CD11b/CD13/CD16 maturation pattern, with <1% of CD16+CD10+ mature neutrophils; and 13% of abnormal CD45+, CD34−, CD117+high MC with a relatively immature (CD123+high, FcεRI/IgE+ low, and HLA-DR+high), activated (CD63+, CD69+), and aberrant (CD2−, CD25+, and CD30+) immunophenotype . Cytoplasmic carboxypeptidase and surface CD203 were also positive (data not shown). In addition, FCM performed in PB, showed 3% CD45+low, CD117+, CD34+ MPC, and 21% of CD45+low, CD117+, CD34− MCP, which were phenotypically similar to the correspondent BM cell populations, at least for the cell surface markers tested, but not CD45+, CD34−, and CD117+ high MC .\nBone marrow trephine biopsy revealed a hypercellular marrow with increased proportions of immature MPO+ myeloid cells and morphologically atypical CD117+ fusiform MC forming perivascular dense aggregates, and grade 2 fibrosis . Skin biopsy was not performed.\nCytogenetic analyses of at least 20 Giemsa-banded BM cell metaphases obtained from unstimulated 24 hour cultures disclosed a 46,XX karyotype, without numerical or structural abnormalities. Genetic studies using probes for relevant targets, including t(15;17) PML-RARA, t(8;21) RUNX1-RUNX1T1, inv(16) CBFB-MYH11, and t(9,22) BCR-ABL, gave negative results. Tests for FLT3 (FMS-like tyrosine kinase 3) and NPM-1 (Nucleophosmin-1) gene mutations were also negative. KIT mutation at the codon 816 (D816V) (A7176T) was detected in all sorted BM cell populations, except in T cells; BM cells harboring the KIT D816V mutation included MC, CD34+ cells, CD34-HLA-DR-, CD34-HLA-DR+, and CD34-HLA-DR++ cells.\nAbdominopelvic computerized tomography scan affirmed hepatomegaly (18.5 cm) and mild splenomegaly (13 cm) with small hypodense nodules (maximum diameter 10 mm) and revealed retroperitoneal adenopathies forming a conglomerate extending from the lesser gastric curvature and involving the large vessels; the largest adenopathy was in the hepatic-duodenal ligament and had 2.4 cm of major diameter. There was also a lamina of peritoneal liquid in pelvic cavitation.\nDigestive endoscopy revealed slight reduced distensibility of the gastric body, which had a congestive mucosa with foci of erythema, and the duodenum had a congestive and micronodular mucosa. Biopsies were not performed due to severe thrombocytopenia. Skeleton radiography did not reveal osteolytic lesions. Thorax radiography had no evidence of mediastinal enlargement, lung consolidations, or pleural effusions.\nAccording to the WHO criteria [, ], and to the consensus recommendations of the EU/US-CGM and the ECNM , the patient was diagnosed with KIT D816V+ MCL associated with AML with normal karyotype. She was immediately started with oral corticosteroids (prednisolone, 60 mg/day for one week, tapered to 20 mg/day over 1 month, and then maintaining 20 mg/day) and disodium cromoglycate (200 mg capsules, 4 times daily), and H1 (cetirizine, 10 mg/day, orally) and H2 (ranitidine, 150 mg twice a day, orally) antihistamines, which ameliorate the symptomatology. Then, she received two cycles of cladribine (0.14 mg/kg/day, administered over a 2-hour infusion for 5 days) with one month of interval, and the serum tryptase levels transiently decreased to 41 μg/L .\nOne month after, she maintained constitutional symptoms, hepatomegaly, and pancytopenia, and she developed cutaneous and mucosal hemorrhage (petechial rash, epistaxis, and spontaneous oral cavity bleeding), myalgia, and bone pain. By that time, the serum tryptase serum levels had increased to 123 μg/L , and the BM aspirate showed 47.0% myeloblasts, 8% promyelocytes, and 7.0% MC. Bone marrow FCM revealed 3% MPC (CD45+low, CD34+, CD117+, FcεRI/IgE−, CD2−, and CD25−/+), 7% MCP (CD45+ low, CD34−, CD117+, FcεRI/IgE+low, CD2−, and CD25+), 46% of immature granulocytic cells (almost complete maturational arrest at the promyelocyte stage), and 7% of CD45+, CD34−, CD117+ high, CD2−, and CD25+ MC. Peripheral blood counts were WBC 2.07 × 109/L, neutrophils 4.0% (0.08 × 109/L), MC 41.0%, BC 9.0%; Hg 8.8 g/dl; and platelets 28 × 109/L. Flow cytometry studies performed in the PB showed 48% CD45+ low, CD117+, CD34−, FcεRI/IgE+low, CD25+, CD2− MCP, 4% CD45+low, CD34+, CD117+, FcεRI/IgE−, CD25−/+, CD2− MPC; once again, circulating CD45+, CD34−, CD117+high, CD2−, CD25+ MC were not observed. By that time, she received induction therapy for AML consisting of two cycles of idarubicin (12 mg/m2/day, intravenous, for 3 days) and cytosine arabinoside (AraC) (100 mg/m2/day, intravenous, for 7 days), achieving hematological remission and normal tryptase levels after the second induction course . At that time, the BM smears were slightly hypocellular with 1.3% of BC and no MC. Bone marrow FCM studies detected 1.5% of CD117+ CD34+ MPC, 54% maturing granulocytic cells, from which 26% were promyelocytes, 53% were metamyelocytes and myelocytes, and 21% were mature neutrophils, and 0.03% were phenotypically abnormal MC (0.02% CD117+ CD34− CD2− CD25−/+low, FcεRI/IgE+ MCP, and 0.01% CD117+high CD34−, CD2−, CD25+, FcεRI/IgE+low MC). Consolidation therapy performed in the subsequent 2 months consisted of two courses of high-dose AraC (2 g/m2, intravenous).\nAs complication of treatment she had bartholinite, treated with piperacillin plus tazobactam, and metronidazole; oral mucositis grade II controlled with tramadol; febrile neutropenia with bacteremia by Escherichia Coli treated with piperacillin plus tazobactam; pneumonia without respiratory insufficiency, which was responsive to imipenem plus vancomycin, and pseudomembranous colitis by Clostridium difficile, treated with metronidazole.\nTwo months after the second course of consolidation chemotherapy, the patient received isogroup HLA-identical related allogeneic HSCT from her sister (10/10 match) (5.09 × 106/kg nonmanipulated peripheral blood CD34+ cells, totalizing 322 × 106 CD34+ cells). The reduced-intensity conditioning regimen included fludarabine (30 mg/m2/day for 5 days) and busulfan (4 mg/kg/day for 2 days). As acute complication, she had febrile neutropenia treated with meropenem. On day 30 after HSCT, she had recovery of the hematological counts, and no myeloblasts or MC were seen in the PB. Unfortunately, the BM aspirate was hypocellular and results from BM studies were unevaluable. Abdominal echography revealed stable hepatomegaly (17.5 cm), without splenomegaly, or adenomegalies. Three months after HSCT a complete chimerism was documented in PB and BM neutrophils, monocytes, and lymphocytes. She developed a chronic graft versus host disease with cutaneous manifestations, controlled with cyclosporine A and mycophenolate mofetil. By the time of this report (24 months after the diagnosis, 15 months after HSCT), she maintains normal serum tryptase levels, complete hematological remission, and complete chimerism in PB .", + "fulltext_subclaims": [ + "The patient is a 41-year-old Caucasian woman.", + "She had a one-month history of asthenia, anorexia, fever, abdominal pain, early postprandial surfeit, and diarrhea.", + "She had a past history of an intermittent migratory pruritic maculopapular rash.", + "She had mild episodes of flushing that had never been investigated.", + "She had hypothyroidism.", + "She had an anxiety disorder.", + "She had emotional instability.", + "She had smoked 20 cigarettes a day since the age of 13.", + "There was no history of allergies or other pathologies.", + "When first observed at the hospital, she had a fever.", + "When first observed at the hospital, she had a dark spot on the tongue.", + "When first observed at the hospital, she had a slightly pruritic brownish erythematous maculopapular skin rash predominantly in the upper limbs.", + "When first observed at the hospital, she had hepatomegaly.", + "When first observed at the hospital, she had splenomegaly.", + "There was no peripheral lymphadenopathy.", + "Peripheral blood counts revealed pancytopenia.", + "Hemoglobin was 11.0 g/dl.", + "Platelets were 16 × 109/L.", + "White blood cells were 4.25 × 109/L.", + "Neutrophils were 7.0%.", + "Blast cells were 6%.", + "Cells with metachromatic cytoplasmic granules were 20%.", + "These cells were initially classified as basophils by morphology.", + "The immunophenotypic study revealed them to be an abnormal immature MC.", + "Serum lactate dehydrogenase was 369 U/L.", + "Total bilirubin was 1.2 mg/dl.", + "Direct bilirubin was 1.1 mg/dl.", + "Indirect bilirubin was 1.14 mg/dl.", + "Alanine transaminase was 90 U/L.", + "Aspartate transaminase was 36 U/L.", + "Alkaline phosphatase was 731 U/L.", + "Gamma-glutamyl transferase was 638 U/L.", + "Serum albumin was 32 g/L.", + "Serum IgG was 522 mg/dl.", + "Serum IgA was 127 mg/dl.", + "Serum IgM was 170 mg/dl.", + "Serum tryptase levels were 184 μg/L.", + "Bone marrow smears showed 24% myeloperoxidase (MPO) positive BC.", + "Bone marrow smears showed 17% promyelocytes.", + "Bone marrow smears showed 4% myelocytes.", + "Bone marrow smears showed 3% metamyelocytes + neutrophils.", + "Bone marrow smears showed 30% erythroid lineage.", + "Bone marrow smears showed 16% morphologically abnormal toluidine blue positive MC.", + "Flow cytometry of the BM aspirate revealed 12% of CD45+ (low), CD117+, CD34+ myeloid precursor cells.", + "Flow cytometry of the BM aspirate revealed 5% of CD45+ (low), CD117+, CD34− MC precursors.", + "Flow cytometry of the BM aspirate revealed 34% promyelocytes with an aberrant phenotype.", + "Flow cytometry of the BM aspirate revealed a maturation blockage at the promyelocyte level.", + "Flow cytometry of the BM aspirate revealed 13% of abnormal CD45+, CD34−, CD117+high MC.", + "Bone marrow trephine biopsy revealed a hypercellular marrow.", + "Bone marrow trephine biopsy revealed increased proportions of immature MPO+ myeloid cells.", + "Bone marrow trephine biopsy revealed morphologically atypical CD117+ fusiform MC forming perivascular dense aggregates.", + "Bone marrow trephine biopsy revealed grade 2 fibrosis.", + "Cytogenetic analyses disclosed a 46,XX karyotype.", + "Tests for t(15;17) PML-RARA, t(8;21) RUNX1-RUNX1T1, inv(16) CBFB-MYH11, and t(9,22) BCR-ABL were negative.", + "Tests for FLT3 and NPM-1 gene mutations were negative.", + "KIT mutation at the codon 816 (D816V) was detected in all sorted BM cell populations, except in T cells.", + "Abdominopelvic computerized tomography scan affirmed hepatomegaly (18.5 cm).", + "Abdominopelvic computerized tomography scan revealed retroperitoneal adenopathies forming a conglomerate.", + "The largest adenopathy was in the hepatic-duodenal ligament and had 2.4 cm of major diameter.", + "Digestive endoscopy revealed slight reduced distensibility of the gastric body.", + "Digestive endoscopy revealed a congestive mucosa with foci of erythema.", + "Digestive endoscopy revealed a congestive and micronodular mucosa in the duodenum.", + "Biopsies were not performed due to severe thrombocytopenia.", + "The patient was diagnosed with KIT D816V+ MCL associated with AML with normal karyotype.", + "She was started with oral corticosteroids (prednisolone, 60 mg/day for one week).", + "She received two cycles of cladribine (0.14 mg/kg/day, administered over a 2-hour infusion for 5 days).", + "She received induction therapy for AML consisting of two cycles of idarubicin and cytosine arabinoside.", + "She received consolidation therapy consisting of two courses of high-dose AraC.", + "She received isogroup HLA-identical related allogeneic HSCT from her sister.", + "The reduced-intensity conditioning regimen included fludarabine and busulfan.", + "On day 30 after HSCT, she had recovery of the hematological counts.", + "Three months after HSCT a complete chimerism was documented in PB and BM.", + "By the time of this report, she maintains normal serum tryptase levels.", + "By the time of this report, she maintains complete hematological remission.", + "By the time of this report, she maintains complete chimerism in PB." + ], + "summary": "A 41-year-old woman presented with asthenia, anorexia, fever, epigastralgia, and diarrhea. She had a maculopapular skin rash, hepatosplenomegaly, retroperitoneal adenopathies, pancytopenia, 6% blast cells (BC) and 20% MC in the peripheral blood, elevated lactate dehydrogenase, cholestasis, hypoalbuminemia, hypogammaglobulinemia, and increased serum tryptase (184 μg/L). The bone marrow (BM) smears showed 24% myeloblasts, 17% promyelocytes, and 16% abnormal toluidine blue positive MC, and flow cytometry revealed 12% myeloid BC, 34% aberrant promyelocytes, a maturation blockage at the myeloblast/promyelocyte level, and 16% abnormal CD2-CD25+ MC. The BM karyotype was normal, and the KIT D816V mutation was positive in BM cells. The diagnosis of MCL associated with AML was assumed. The patient received corticosteroids, disodium cromoglycate, cladribine, idarubicin and cytosine arabinoside, high-dose cytosine arabinoside, and hematopoietic stem cell transplantation (HSCT). The outcome was favorable, with complete hematological remission two years after diagnosis and one year after HSCT.", + "summary_subclaims": [ + "The patient was a 41-year-old woman.", + "She presented with asthenia.", + "She presented with anorexia.", + "She presented with fever.", + "She presented with epigastralgia.", + "She presented with diarrhea.", + "She had a maculopapular skin rash.", + "She had hepatosplenomegaly.", + "She had retroperitoneal adenopathies.", + "She had pancytopenia.", + "She had 6% blast cells in the peripheral blood.", + "She had 20% mast cells in the peripheral blood.", + "She had elevated lactate dehydrogenase.", + "She had cholestasis.", + "She had hypoalbuminemia.", + "She had hypogammaglobulinemia.", + "She had increased serum tryptase (184 μg/L).", + "The bone marrow smears showed 24% myeloblasts.", + "The bone marrow smears showed 17% promyelocytes.", + "The bone marrow smears showed 16% abnormal toluidine blue positive mast cells.", + "Flow cytometry revealed 12% myeloid blast cells.", + "Flow cytometry revealed 34% aberrant promyelocytes.", + "Flow cytometry showed a maturation blockage at the myeloblast/promyelocyte level.", + "Flow cytometry revealed 16% abnormal CD2-CD25+ mast cells.", + "The bone marrow karyotype was normal.", + "The KIT D816V mutation was positive in bone marrow cells.", + "The diagnosis of mast cell leukemia associated with acute myeloid leukemia was assumed.", + "The patient received corticosteroids.", + "The patient received disodium cromoglycate.", + "The patient received cladribine.", + "The patient received idarubicin and cytosine arabinoside.", + "The patient received high-dose cytosine arabinoside.", + "The patient received hematopoietic stem cell transplantation.", + "The outcome was favorable.", + "The patient achieved complete hematological remission two years after diagnosis.", + "The patient achieved complete hematological remission one year after hematopoietic stem cell transplantation." + ] + }, + { + "id": "multiclinsum_test_327_en.txt", + "fulltext": "A 75-year-old woman was admitted to our hospital due to a 2-year history of gradually progressive gait disturbance. She had suffered from RA since the age of 25. Because of an exacerbation of this disease, she started taking prednisolone (5 mg/day) and sulfasalazine at 67 years, and had been continuously treated with minocycline (200 mg/day) since the age of 68. She noticed a gradual increase in blue-black skin pigmentation on both legs at 72 years. Thereafter, she began to have difficulty walking, and would frequently catch the tip of her foot on the ground. No exposure to other drugs known to cause pigmentary changes was recorded.\nExamination of the patient revealed blue-black pigmentation related to minocycline therapy on the distal parts of the legs . The muscle strength was normal in the upper limbs and trunk, but she was unable to perform toe- or heel-walking. There was mild symmetrical weakness and atrophy in the lower limb muscles, but no wide-based gait. Strength testing was performed using Medical Research Council grades, and the results were as follows: hip flexion 4+/5, hip extension 4+/5, knee extension 4/5, knee flexion 4-/5, ankle dorsiflexion 4-/5, and ankle plantar flexion 4-/5. The tendon reflexes were normal except for the absence of ankle jerks. A stocking distribution decrease in appreciation of superficial pain was identified in both legs. Vibration sensation was decreased in the toes and ankles. Laboratory tests, including creatine kinase levels, were normal except for the tests related to RA. Chest roentgenogram and electrocardiogram showed no abnormalities. A nerve conduction study demonstrated no detectable abnormalities except for low amplitude in the bilateral sural nerve action potentials. Needle electromyography showed low amplitude and short duration motor-unit potentials with early recruitment in the quadriceps femoris, biceps femoris and tibialis anterior muscles. No abnormal spontaneous activity was seen in any of the muscles. Skeletal muscle CT revealed diffuse muscular atrophy of the lower extremities. Because the patient was suspected of having myopathy and sensory neuropathy, peroneus muscle and sural nerve biopsies were performed after informed consent was obtained.\nThe biopsied specimens were snap-frozen in isopentane-liquid nitrogen, and cryosections were stained with a standard battery of histological and histochemical reactions. Paraffin-embedded tissue sections were also stained with Prussian blue stain (for iron), Masson Fontana preparation (for melanin) and hydrogen peroxide melanin bleach. Histopathological studies of the biopsied muscle revealed modest variability in myofiber diameter with scattered angular atrophic fibers . There were a considerable number of atrophic fibers with rimmed vacuoles , and multiple collections of granular pigment-containing histiocytes in the endomysial and perimysial perivascular areas. The granules and rimmed vacuoles showed high acid phosphatase activity . The pigmentation was mainly found outside the myofibers, but the NADH-tetrazolium reductase reaction readily identified dark-brown depositions in some fibers. Almost all of the rimmed vacuoles contained granular depositions . No necrotic or regenerating fibers were present. There was no inflammatory infiltrate, except for histiocytes containing pigment that stained bright blue with the Prussian blue . This histiocytic pigment stained black on a Masson Fontana preparation , bleached in response to potassium permanganate, and showed no fluoresce under ultraviolet light, indicating that it was composed of iron and melanin.\nElectron microscopy was performed on glutaraldehyde-fixed tissue using a standard electron microscopic processing protocol and a transmission electron microscope. Electron microscopy revealed that the pigment granules were localized in the cytoplasm of histiocytes, in the spaces between myofibers, and adjacent to small blood vessels . In the myofibers, the granules were localized in the subsarcolemmal cytoplasm, either individually or in clusters . Remarkably, autophagic vacuoles were consistently observed in association with many of the granular pigment clusters . Two distinct morphological patterns were evident among the granules found in myofibers: irregularly shaped, highly electron-dense granules, and membrane-bound vesicles of differing electron density with distinct internal structures, often associated with small lipid droplets.\nIn addition to the standard battery of histological stains, the sural nerve biopsy specimen was embedded in epoxy resin and examined by light and electron microscopy. Light microscopy of the sural nerve showed a reduction in the number of large diameter myelinated fibers, but no other specific features . However, Prussian blue and Masson Fontana staining revealed perivascular deposits of iron and melanin in the epineurial blood vessels. Electron microscopy revealed a few highly electron-dense granules in the cytoplasm of Schwann cells, where the myelin sheath was disrupted .", + "fulltext_subclaims": [ + "The patient was a 75-year-old woman.", + "She had a 2-year history of gradually progressive gait disturbance.", + "She had suffered from RA since the age of 25.", + "She started taking prednisolone (5 mg/day) and sulfasalazine at 67 years.", + "She had been continuously treated with minocycline (200 mg/day) since the age of 68.", + "She noticed a gradual increase in blue-black skin pigmentation on both legs at 72 years.", + "She began to have difficulty walking, and would frequently catch the tip of her foot on the ground.", + "No exposure to other drugs known to cause pigmentary changes was recorded.", + "Examination revealed blue-black pigmentation related to minocycline therapy on the distal parts of the legs.", + "The muscle strength was normal in the upper limbs and trunk.", + "She was unable to perform toe- or heel-walking.", + "There was mild symmetrical weakness and atrophy in the lower limb muscles.", + "No wide-based gait was observed.", + "Strength testing was performed using Medical Research Council grades.", + "The results were as follows: hip flexion 4+/5, hip extension 4+/5, knee extension 4/5, knee flexion 4-/5, ankle dorsiflexion 4-/5, and ankle plantar flexion 4-/5.", + "The tendon reflexes were normal except for the absence of ankle jerks.", + "A stocking distribution decrease in appreciation of superficial pain was identified in both legs.", + "Vibration sensation was decreased in the toes and ankles.", + "Laboratory tests, including creatine kinase levels, were normal except for the tests related to RA.", + "Chest roentgenogram and electrocardiogram showed no abnormalities.", + "A nerve conduction study demonstrated no detectable abnormalities except for low amplitude in the bilateral sural nerve action potentials.", + "Needle electromyography showed low amplitude and short duration motor-unit potentials with early recruitment in the quadriceps femoris, biceps femoris and tibialis anterior muscles.", + "No abnormal spontaneous activity was seen in any of the muscles.", + "Skeletal muscle CT revealed diffuse muscular atrophy of the lower extremities.", + "The patient was suspected of having myopathy and sensory neuropathy.", + "Peroneus muscle and sural nerve biopsies were performed after informed consent was obtained.", + "The biopsied specimens were snap-frozen in isopentane-liquid nitrogen.", + "Cryosections were stained with a standard battery of histological and histochemical reactions.", + "Paraffin-embedded tissue sections were also stained with Prussian blue stain (for iron), Masson Fontana preparation (for melanin) and hydrogen peroxide melanin bleach.", + "Histopathological studies of the biopsied muscle revealed modest variability in myofiber diameter with scattered angular atrophic fibers.", + "There were a considerable number of atrophic fibers with rimmed vacuoles.", + "Multiple collections of granular pigment-containing histiocytes were found in the endomysial and perimysial perivascular areas.", + "The granules and rimmed vacuoles showed high acid phosphatase activity.", + "The pigmentation was mainly found outside the myofibers.", + "The NADH-tetrazolium reductase reaction readily identified dark-brown depositions in some fibers.", + "Almost all of the rimmed vacuoles contained granular depositions.", + "No necrotic or regenerating fibers were present.", + "There was no inflammatory infiltrate, except for histiocytes containing pigment that stained bright blue with the Prussian blue.", + "This histiocytic pigment stained black on a Masson Fontana preparation.", + "The pigment bleached in response to potassium permanganate.", + "The pigment showed no fluorescence under ultraviolet light.", + "Electron microscopy was performed on glutaraldehyde-fixed tissue using a standard electron microscopic processing protocol and a transmission electron microscope.", + "Electron microscopy revealed that the pigment granules were localized in the cytoplasm of histiocytes, in the spaces between myofibers, and adjacent to small blood vessels.", + "In the myofibers, the granules were localized in the subsarcolemmal cytoplasm, either individually or in clusters.", + "Autophagic vacuoles were consistently observed in association with many of the granular pigment clusters.", + "Two distinct morphological patterns were evident among the granules found in myofibers: irregularly shaped, highly electron-dense granules, and membrane-bound vesicles of differing electron density with distinct internal structures, often associated with small lipid droplets.", + "The sural nerve biopsy specimen was embedded in epoxy resin and examined by light and electron microscopy.", + "Light microscopy of the sural nerve showed a reduction in the number of large diameter myelinated fibers, but no other specific features.", + "Prussian blue and Masson Fontana staining revealed perivascular deposits of iron and melanin in the epineurial blood vessels.", + "Electron microscopy revealed a few highly electron-dense granules in the cytoplasm of Schwann cells, where the myelin sheath was disrupted." + ], + "summary": "A 75-year-old woman suffering from RA has been continuously treated with minocycline (200 mg/day) for the past 7 years. During this time, she developed a myopathy that predominantly affected her lower limbs. Histological studies of biopsied muscle revealed scattered atrophic myofibers with rimmed vacuoles that contained pigment granules. Histochemical staining revealed that the pigment comprised both iron and melanin, which is consistent with type II minocycline-induced cutaneous pigmentation. Under electron microscopy, autophagic vacuoles were consistently observed in association with numerous collections of pigment granules.", + "summary_subclaims": [ + "The patient is a 75-year-old woman with rheumatoid arthritis.", + "She has been continuously treated with minocycline (200 mg/day) for the past 7 years.", + "She developed a myopathy that predominantly affected her lower limbs.", + "Histological studies of biopsied muscle revealed scattered atrophic myofibers with rimmed vacuoles that contained pigment granules.", + "Histochemical staining revealed that the pigment comprised both iron and melanin.", + "The pigment findings are consistent with type II minocycline-induced cutaneous pigmentation.", + "Under electron microscopy, autophagic vacuoles were consistently observed in association with numerous collections of pigment granules." + ] + }, + { + "id": "multiclinsum_test_638_en.txt", + "fulltext": "The patient was a 51-year-old, female sex, blood group O, with advanced decompensated primary biliary cirrhosis presenting with refractory ascites, sarcopenia, portal hypertension and significant jaundice. The United Kingdom Model for End-Stage Liver Disease (UKELD) score was 61 [, , ] and she was listed for LT. This patient received a DCD liver from a 74-year-old, male sex, donor. Further donor details are presented in . Recipient laboratorial data on the index admission for transplantation were summarised in .\nThe graft had normal hepatic artery anatomy, but an extensive atheromatous plaque up to the GDA. During implantation, the graft GDA was divided obliquely along the main hepatic artery stem and an endarterectomy was done. A plaque free portion of the hepatic artery above the GDA was obtained for direct anastomosis to the native CHA at the GDA junction; thereafter, a short, straight and non-redundant arterial reconstruction was performed. The anastomosis width was just over 6 mm, there were good pulse waves and the resistance index was confirmed by doppler ultrasound intra-operatively.\nSurgical times are presented in . In terms of postoperative complications, this patient developed renal dysfunction and fluid overload in the immediate post-operative period, requiring temporary renal support. Additionally, further respiratory infection required the intensive care unit (ICU) up to post-operative day (POD) 9. Patient also developed delayed graft function with prolonged cholestasis. The bilirubin level was 266 mmol/L on POD 29 and it improved gradually down to 69 mmol/L by POD 49 when the patient was discharged. It was within the normal range (18 mmol/L) after 3 months of the transplant. During hospitalisation 4500 units of low molecular heparin and 75 mg of aspirin were given daily from POD 1 onward, as per unit protocol. The haemoglobin level was maintained around 80 g/L and platelets on an average of 80,000 counts until POD 5. Immunosuppression was standard, and the biochemistry was within the normal range at 4 months follow up. An ultrasound scan at 4 months post-transplant showed patent graft vessels and a non-dilated biliary system without evidence of HAT or hepatic artery stenosis (, ).", + "fulltext_subclaims": [ + "The patient was a 51-year-old, female sex, blood group O.", + "The patient had advanced decompensated primary biliary cirrhosis.", + "The patient presented with refractory ascites.", + "The patient had sarcopenia.", + "The patient had portal hypertension.", + "The patient had significant jaundice.", + "The United Kingdom Model for End-Stage Liver Disease (UKELD) score was 61.", + "The patient was listed for liver transplantation.", + "The patient received a DCD liver from a 74-year-old, male sex, donor.", + "The graft had normal hepatic artery anatomy.", + "The graft had an extensive atheromatous plaque up to the GDA.", + "During implantation, the graft GDA was divided obliquely along the main hepatic artery stem.", + "An endarterectomy was done.", + "A plaque free portion of the hepatic artery above the GDA was obtained for direct anastomosis to the native CHA at the GDA junction.", + "A short, straight and non-redundant arterial reconstruction was performed.", + "The anastomosis width was just over 6 mm.", + "Good pulse waves were confirmed by doppler ultrasound intra-operatively.", + "The resistance index was confirmed by doppler ultrasound intra-operatively.", + "The patient developed renal dysfunction in the immediate post-operative period.", + "The patient developed fluid overload in the immediate post-operative period.", + "The patient required temporary renal support.", + "The patient developed a respiratory infection.", + "The patient required the intensive care unit (ICU) up to post-operative day (POD) 9.", + "The patient developed delayed graft function.", + "The patient had prolonged cholestasis.", + "The bilirubin level was 266 mmol/L on POD 29.", + "The bilirubin level improved gradually down to 69 mmol/L by POD 49.", + "The bilirubin level was within the normal range (18 mmol/L) after 3 months of the transplant.", + "4500 units of low molecular heparin were given daily from POD 1 onward.", + "75 mg of aspirin were given daily from POD 1 onward.", + "The haemoglobin level was maintained around 80 g/L.", + "The platelets were on an average of 80,000 counts until POD 5.", + "Immunosuppression was standard.", + "The biochemistry was within the normal range at 4 months follow up.", + "An ultrasound scan at 4 months post-transplant showed patent graft vessels.", + "An ultrasound scan at 4 months post-transplant showed a non-dilated biliary system.", + "There was no evidence of HAT.", + "There was no evidence of hepatic artery stenosis." + ], + "summary": "In all three cases, endarterectomies were performed by dissection between the atheromatous core and the artery intima using a dissecting spatula, allowing to secure the lumen of the vessel. The native CHA/GDA patch was aligned with the corresponding CHA/GDA patch from the graft for the arterial reconstruction. No vascular complications were seen post-operatively.", + "summary_subclaims": [ + "Endarterectomies were performed by dissection between the atheromatous core and the artery intima.", + "A dissecting spatula was used during the endarterectomies.", + "The native CHA/GDA patch was aligned with the corresponding CHA/GDA patch from the graft.", + "No vascular complications were seen post-operatively." + ] + }, + { + "id": "multiclinsum_test_2200_en.txt", + "fulltext": "A 55-year-old Chinese female was admitted to our hospital complaining of exertional dyspnea for more than 10 years. She had been developing truncal obesity and facial rounding over the past 2 years, without evidence of acne, hirsutism or wide purple striae. The patient had a family history of hypertension and was diagnosed with hypertension 10 years prior to admission, and she had been using irbesartan, metoprolol and nifedipine XR since then. She was also diagnosed with hyperlipidemia and prescribed with statins for 5 years. The patient reported no history of alcohol or drug abuse, in particular, no history of steroid use.\nPhysical examination on admission showed elevated blood pressure (164/104 mmHg) and normal heart rate (74 beats per minute). The patient’s height, body weight and waist circumference were 156 cm, 51 kg and 88 cm, respectively, with a body mass index (BMI) of 20.96 kg/m2. She had a plethoric moon-shaped face, centripetal obesity, buffalo hump, accompanied by ecchymosis and slight edema at both lower limbs. Neurological examination was unremarkable except for slight muscle weakness of the lower-extremities.\nRoutine laboratory examinations showed normal complete blood cell count and hepatorenal parameters, whereas the level of serum triglyceride was slightly elevated. The fasting plasma glucose level was 7.33 mmol/L, and glycosylated hemoglobin (HbA1c) was 6.6% . Endocrinological examinations showed that circadian rhythm of cortisol disappeared, and the level of ACTH was less than 1.00 ng/L . Twenty-four-hour urine free cortisol (24 h UFC) elevated to 634.8μg/24 h (reference range: 20.26-127.55μg/24 h). The next morning (8 a.m.) serum cortisol level after an overnight 1 mg dexamethasone suppression test (DMST) was 787.5 nmol/L, indicated lack of normal suppression . The diagnosis of ACTH-independent Cushing’s syndrome was therefore established.\nFor differential diagnosis, aldosterone-to-renin ratio (ARR) was measured after discontinuation of irbesartan and nifedipine XR for at least 2 weeks as they might lead to false-negative result. Plasma and urinary catecholamine concentrations were detected as well. The diagnosis of primary aldosteronism (PA) was excluded since both plasma renin activity (PRA) and aldosterone concentration (PAC) were within normal limits along with an ARR value of 2.59 ng/dL: ng/mL.h. Pheochromocytoma was also ruled out based on laboratory findings .\nThree adrenal nodules were found with adrenal contrast-enhanced CT. One on the right side was 2.5 cm in diameter, and the other two on the left side with diameters of 2.3 cm and 0.6 cm, respectively . Magnetic resonance imaging (MRI) of sellar region revealed normal findings. Bone mineral density measured by dual-energy X-ray absorptiometry scans showed that the T score of lumbar spine, femoral neck and the total hip was − 3.0, − 3.2 and − 3.3, respectively, which indicated osteoporosis. In order to locate the functional lesions in this patient, AVS was performed and the concentrations of plasma aldosterone and cortisol were measured from both adrenal veins (AV) and inferior vena cava (IVC). Adrenal venous catheterization was successful, and the hormone levels were shown in Table . The adrenal vein to inferior vena cava cortisol (AV: IVC) gradient was 13.57 on the right side and 13.88 on the left side. The left and right AV to IVC gradient of aldosterone were 5.58 and 6.79 respectively. Moreover, the cortisol/aldosterone ratio (CAR) in adrenal veins was 292.52 on the right and 359.29 on the left, along with a left-to-right odds ratio of 1.23 . In combination with the results of AVS, which indicated non-lateralization, this patient was diagnosed with CS induced by bilateral adrenal excessive cortisol secretion.\nThe patient was treated with metoprolol succinate, rosuvastatin, insulin, calcium and vitamin D supplements during the investigation. Considering her poor cardiac function, a two-step operation was planned. Laparoscopic right adrenalectomy was performed, followed by left adrenalectomy after a two-month interval. Pathological findings of the removed right adrenal mass indicated a yellow adenoma with 2.5 cm in diameter, surrounded by atrophic adrenal tissue .\nOvernight 1 mg DMST was repeated 2 weeks after surgery, which demonstrated no inhibition on the serum cortisol at 8 a.m. on the following day, despite significantly decreased cortisol level post-operation . Therefore, it can be inferred that the autonomous cortisol secretion from left adrenal masses was persistent. The left adrenal gland was then removed and two adenomas were confirmed by pathological examination . The 8 a.m. plasma cortisol after 3 days of bilateral adrenalectomy was 37.30 nmol/L. Hydrocortisone replacement therapy (from 20 mg t.i.d to 20 mg q.d.) was administered after surgery. At 1 year after the operations, the patient lost 4 kg of body weight and the waist circumference reduced to 71 cm. Changes of other laboratory examinations at the last follow-up compared with the first admission were shown in Table .\nAn electronic literature search in PubMed was performed to screen the case reports relating to ACTH-independent Cushing’s syndrome caused by bilateral cortisol-secreting adenomas. Searching words included “Cushing’s syndrome” and “bilateral adrenocortical adenoma”. All reference lists from the main reports and relevant reviews were screened manually for additional eligible studies. The results were limited to full-text articles published in English. Extracted data included the first author’s name, year of publication, country, preoperative diagnostic technique, patient characteristics (gender, age at onset and at diagnosis), lesions size, operative method and tumor cut surface.\nA total of 231 papers were identified, of which, 15 available reports were included in the review . The clinical features in these patients were summarized as following: 1) this disorder seemed predominated in females (male: female ratio 1: 14), with an adult onset (the mean age was 39.6 ± 8.6 years; ranged from 24 to 53 years); 2) the size of bilateral adrenal adenomas ranged from 1.0 to 5.0 cm in diameter, the majority of which were solitary in both sides (12 out of 15, 80%); 3) most of the bilateral adrenal lesions were found to occur synchronously, except that three cases occurred at different periods [, ]; 4) the surrounded adrenal cortex of resected adenomas was atrophic in most cases; 5) although no recurrence was reported postoperatively, long-term outcomes remain unclear with the longest follow-up duration of 123 months .\nAll preoperative diagnoses were established based on endocrinological studies and imaging findings, while the methods used to determine the functional lesions were different. Nine patients underwent adrenocortical scintigraphy with different radio-imaging agents, all of which revealed bilateral adrenal uptake. AVS was performed in eight cases to evaluate the hypersecretion of cortisol, and only two of them applied cortisol gradient adjusted by plasma aldosterone [, ]. All patients underwent surgical resection of adenomas, including ten bilateral total adrenalectomy [, –], three unilateral partial adrenalectomy with contralateral total adrenalectomy [, , ], one bilateral partial adrenalectomy and one bilateral subtotal adrenalectomy . All patients received glucocorticoid replacement therapy postoperatively. It is noteworthy that glucocorticoid therapy was reported to be withdrawn during follow-up in patients who underwent bilateral subtotal adrenalectomy or partial adrenalectomy [–].", + "fulltext_subclaims": [ + "The patient was a 55-year-old Chinese female.", + "She had exertional dyspnea for more than 10 years.", + "She had truncal obesity and facial rounding over the past 2 years.", + "She had no evidence of acne, hirsutism, or wide purple striae.", + "She had a family history of hypertension.", + "She was diagnosed with hypertension 10 years prior to admission.", + "She had been using irbesartan, metoprolol, and nifedipine XR since then.", + "She was diagnosed with hyperlipidemia and prescribed statins for 5 years.", + "She reported no history of alcohol or drug abuse.", + "She had no history of steroid use.", + "On admission, her blood pressure was 164/104 mmHg.", + "Her body mass index was 20.96 kg/m2.", + "She had a plethoric moon-shaped face.", + "She had centripetal obesity.", + "She had a buffalo hump.", + "She had ecchymosis and slight edema at both lower limbs.", + "Neurological examination showed slight muscle weakness of the lower extremities.", + "The fasting plasma glucose level was 7.33 mmol/L.", + "The glycosylated hemoglobin (HbA1c) was 6.6%.", + "The circadian rhythm of cortisol disappeared.", + "The level of ACTH was less than 1.00 ng/L.", + "The 24-hour urine free cortisol was 634.8 μg/24 h.", + "The next morning serum cortisol after an overnight 1 mg dexamethasone suppression test was 787.5 nmol/L.", + "The diagnosis of ACTH-independent Cushing’s syndrome was established.", + "Aldosterone-to-renin ratio (ARR) was measured after discontinuation of irbesartan and nifedipine XR.", + "Plasma and urinary catecholamine concentrations were detected.", + "The diagnosis of primary aldosteronism was excluded.", + "Pheochromocytoma was ruled out based on laboratory findings.", + "Three adrenal nodules were found with adrenal contrast-enhanced CT.", + "The right adrenal nodule was 2.5 cm in diameter.", + "The left adrenal nodules were 2.3 cm and 0.6 cm in diameter.", + "Magnetic resonance imaging of the sellar region revealed normal findings.", + "Bone mineral density T scores were −3.0, −3.2, and −3.3 for lumbar spine, femoral neck, and total hip, respectively.", + "Adrenal venous sampling (AVS) was performed.", + "The right adrenal vein to inferior vena cava cortisol gradient was 13.57.", + "The left adrenal vein to inferior vena cava cortisol gradient was 13.88.", + "The cortisol/aldosterone ratio in adrenal veins was 292.52 on the right and 359.29 on the left.", + "The left-to-right odds ratio was 1.23.", + "The patient was diagnosed with Cushing’s syndrome induced by bilateral adrenal excessive cortisol secretion.", + "The patient was treated with metoprolol succinate, rosuvastatin, insulin, calcium, and vitamin D supplements.", + "A two-step operation was planned.", + "Laparoscopic right adrenalectomy was performed.", + "The right adrenal mass was a yellow adenoma with 2.5 cm in diameter.", + "The right adrenal mass was surrounded by atrophic adrenal tissue.", + "Overnight 1 mg dexamethasone suppression test was repeated 2 weeks after surgery.", + "The serum cortisol at 8 a.m. after surgery showed no inhibition.", + "The cortisol level was significantly decreased post-operation.", + "The left adrenal gland was then removed.", + "Two adenomas were confirmed by pathological examination.", + "The 8 a.m. plasma cortisol after 3 days of bilateral adrenalectomy was 37.30 nmol/L.", + "Hydrocortisone replacement therapy was administered after surgery.", + "At 1 year after the operations, the patient lost 4 kg of body weight.", + "The patient’s waist circumference reduced to 71 cm.", + "An electronic literature search in PubMed was performed.", + "The search words included “Cushing’s syndrome” and “bilateral adrenocortical adenoma”.", + "A total of 231 papers were identified.", + "Fifteen reports were included in the review.", + "The disorder seemed to be predominated in females with a male:female ratio of 1:14.", + "The mean age at onset was 39.6 ± 8.6 years.", + "The size of bilateral adrenal adenomas ranged from 1.0 to 5.0 cm in diameter.", + "Most cases had solitary lesions in both sides.", + "Three cases had adrenal lesions occurring at different periods.", + "The surrounded adrenal cortex of resected adenomas was atrophic in most cases.", + "No recurrence was reported postoperatively.", + "The longest follow-up duration was 123 months.", + "All preoperative diagnoses were established based on endocrinological studies and imaging findings.", + "Nine patients underwent adrenocortical scintigraphy.", + "All scintigraphy cases revealed bilateral adrenal uptake.", + "AVS was performed in eight cases.", + "Two cases applied cortisol gradient adjusted by plasma aldosterone.", + "All patients underwent surgical resection of adenomas.", + "Ten patients underwent bilateral total adrenalectomy.", + "Three patients underwent unilateral partial adrenalectomy with contralateral total adrenalectomy.", + "One patient underwent bilateral partial adrenalectomy.", + "One patient underwent bilateral subtotal adrenalectomy.", + "All patients received glucocorticoid replacement therapy postoperatively.", + "Glucocorticoid therapy was reported to be withdrawn during follow-up in patients who underwent bilateral subtotal or partial adrenalectomy." + ], + "summary": "We herein report a new case of a Chinese female patient with a complaint of exertional dyspnea for over 10 years. ACTH-independent CS was diagnosed based on undetectable ACTH and unsuppressed cortisol levels by dexamethasone. Computed tomography (CT) scan indicated bilateral adrenal masses, and adrenal venous sampling (AVS) adjusted by plasma aldosterone revealed hypersecretion of cortisol from both adrenal glands. Bilateral cortisol-secreting adrenal adenomas were suspected and confirmed by the postoperative pathology in subsequent two-step bilateral laparoscopic adrenalectomy. The symptoms and signs of CS relieved after surgery with continuous glucocorticoid replacement.", + "summary_subclaims": [ + "The patient is a Chinese female.", + "The patient had exertional dyspnea for over 10 years.", + "ACTH-independent Cushing's syndrome was diagnosed.", + "ACTH levels were undetectable.", + "Cortisol levels were unsuppressed by dexamethasone.", + "Computed tomography showed bilateral adrenal masses.", + "Adrenal venous sampling adjusted by plasma aldosterone was performed.", + "Cortisol hypersecretion was observed from both adrenal glands.", + "Bilateral cortisol-secreting adrenal adenomas were suspected.", + "Postoperative pathology confirmed bilateral cortisol-secreting adrenal adenomas.", + "A two-step bilateral laparoscopic adrenalectomy was performed.", + "Symptoms and signs of Cushing's syndrome improved after surgery.", + "Glucocorticoid replacement was provided continuously after surgery." + ] + }, + { + "id": "multiclinsum_test_2739_en.txt", + "fulltext": "A 42-year-old woman with progressive exertional dyspnoea and World Health Organization functional class (WHO FC) III–IV and a recent episode of haemoptysis was referred to our Pulmonary Hypertension Centre. She had no cardiovascular risk factors and family medical history was not available because the patient was adopted at the age of 12. She had no history of human immunodeficiency virus infection, no exposure to drugs or toxins involved in the development of PAH, no history of chronic liver disease, deep vein thrombosis, or connective tissue disease. At our first physical examination, the patient did not have elevated jugular venous pressure, hepatomegaly, ascites, or peripheral oedema; but the auscultation revealed an accentuated pulmonary component of the second heart sound. The electrocardiogram showed sinus rhythm and right bundle branch block. Transthoracic echocardiography confirmed the suspicion of pulmonary hypertension (PH): systolic pulmonary arterial pressure was estimated to be 80 mmHg, the pulmonary artery trunk was dilated and the right ventricular (RV) outflow tract acceleration time was shortened. No pericardial effusion was detected. Six minutes walking test (6MWT) showed impairment in functional capacity (220 m). Cardiac magnetic resonance (CMR) imaging showed a hypertrophic, normal-volume right ventricle with mild depressed global systolic function (RV ejection fraction 51%) and no evidence of congenital heart disease. The left ventricle ejection fraction was normal with flattening of the interventricular septum . High-resolution computed tomography excluded parenchymal lung disease and perfusion lung scan was negative for mismatched perfusion defects, ruling out the suspect of chronic thromboembolic PH . Although the patient had never been complaining of angina coronary angiography was performed to exclude left main stem coronary artery compression by the dilated pulmonary artery trunk. The exam did not demonstrate any coronary artery abnormality. Finally, right heart catheterization (RHC) confirmed pre-capillary PH with severe reduction of cardiac index and a remarkable increase of pulmonary vascular resistance . The patient was non-responder to acute vasoreactivity testing performed by inhaled nitric oxide and a conclusive diagnosis of IPAH was made. After a comprehensive clinical assessment, based on ESC/ERS table risk stratification, the patient was classified as high risk and an initial combination therapy including a parenteral prostacyclin analogue (PCA) was proposed. However, the patient refused PCA for personal concerns about the potential side effects. Consequently, oral therapy including low-dose diuretics (furosemide 50 mg once daily) and specific drugs acting on the three separate signalling pathway involved in PAH were used. So a phosphodiesterase-5 inhibitor (Sildenafil 20 mg three times daily), an endothelin receptor antagonist (Macitentan 10 mg once daily), and selexipag were started under strict medical supervision. Selexipag was started at dosage of 200 μg twice daily and titrated up to 1200 μg twice daily over 30 days. The therapy was well tolerated without hypotension. At 3- and 6-month follow-up on the same medication we found a significant clinical and haemodynamic improvement as confirmed by a comprehensive revaluation including echocardiography, CMR , brain natriuretic peptide, 6MWT, and RHC . So the patient was reclassified as low risk . After 6 months clinical conditions were still stable on the same medical regimen, referral for lung transplantation is under evaluation.", + "fulltext_subclaims": [ + "The patient is a 42-year-old woman.", + "She had progressive exertional dyspnoea.", + "She was in World Health Organization functional class III–IV.", + "She had a recent episode of haemoptysis.", + "She was referred to the Pulmonary Hypertension Centre.", + "She had no cardiovascular risk factors.", + "Family medical history was not available because the patient was adopted at the age of 12.", + "She had no history of human immunodeficiency virus infection.", + "She had no exposure to drugs or toxins involved in the development of PAH.", + "She had no history of chronic liver disease.", + "She had no history of deep vein thrombosis.", + "She had no history of connective tissue disease.", + "The physical examination did not show elevated jugular venous pressure.", + "The physical examination did not show hepatomegaly.", + "The physical examination did not show ascites.", + "The physical examination did not show peripheral oedema.", + "Auscultation revealed an accentuated pulmonary component of the second heart sound.", + "The electrocardiogram showed sinus rhythm.", + "The electrocardiogram showed right bundle branch block.", + "Transthoracic echocardiography confirmed the suspicion of pulmonary hypertension.", + "Systolic pulmonary arterial pressure was estimated to be 80 mmHg.", + "The pulmonary artery trunk was dilated.", + "The right ventricular outflow tract acceleration time was shortened.", + "No pericardial effusion was detected.", + "The six minutes walking test showed impairment in functional capacity.", + "The six minutes walking test result was 220 m.", + "Cardiac magnetic resonance imaging showed a hypertrophic right ventricle.", + "The right ventricle had normal volume.", + "The right ventricle had mild depressed global systolic function.", + "The right ventricular ejection fraction was 51%.", + "There was no evidence of congenital heart disease.", + "The left ventricle ejection fraction was normal.", + "The interventricular septum was flattened.", + "High-resolution computed tomography excluded parenchymal lung disease.", + "Perfusion lung scan was negative for mismatched perfusion defects.", + "Right heart catheterization confirmed pre-capillary PH.", + "There was a severe reduction of cardiac index.", + "There was a remarkable increase of pulmonary vascular resistance.", + "The patient was a non-responder to acute vasoreactivity testing.", + "The patient was diagnosed with idiopathic pulmonary arterial hypertension.", + "The patient was classified as high risk.", + "An initial combination therapy including a parenteral prostacyclin analogue was proposed.", + "The patient refused the parenteral prostacyclin analogue.", + "Oral therapy including low-dose diuretics was used.", + "Oral therapy included specific drugs acting on the three separate signalling pathways involved in PAH.", + "Sildenafil 20 mg three times daily was started.", + "Macitentan 10 mg once daily was started.", + "Selexipag was started.", + "Selexipag was started at a dosage of 200 μg twice daily.", + "Selexipag was titrated up to 1200 μg twice daily over 30 days.", + "The therapy was well tolerated without hypotension.", + "At 3- and 6-month follow-up, there was significant clinical and haemodynamic improvement.", + "The patient was reclassified as low risk.", + "After 6 months, clinical conditions were still stable on the same medical regimen.", + "Referral for lung transplantation is under evaluation." + ], + "summary": "A 42-year-old woman with worsening dyspnoea (World Health Organization functional class III-IV) and suspected PH at echocardiographic examination was evaluated in our Pulmonary Hypertension Centre. Right heart catheterization showed pre-capillary PH with reduced cardiac index and increased pulmonary vascular resistance. High-resolution computed tomography excluded parenchymal lung disease and ventilation/perfusion (V/Q) lung scan was negative for mismatched perfusion defects so the conclusive diagnosis was high-risk idiopathic pulmonary arterial hypertension (PAH). The patient refused an initial combination therapy including a parenteral prostacyclin analogue (PCA) in accordance with the ESC/ERS guidelines, so an off-label triple oral combination therapy including a phosphodiesterase-5 inhibitor, an endothelin receptor antagonist, and selexipag was started. At 3- and 6-month follow-up we found a clinical and haemodynamic improvement, so the patient was reclassified as low risk. Her clinical condition is currently stable.", + "summary_subclaims": [ + "The patient is a 42-year-old woman.", + "She has worsening dyspnoea.", + "Her World Health Organization functional class is III-IV.", + "Echocardiographic examination suggested PH.", + "Right heart catheterization showed pre-capillary PH.", + "Right heart catheterization showed reduced cardiac index.", + "Right heart catheterization showed increased pulmonary vascular resistance.", + "High-resolution computed tomography excluded parenchymal lung disease.", + "Ventilation/perfusion (V/Q) lung scan was negative for mismatched perfusion defects.", + "The conclusive diagnosis was high-risk idiopathic pulmonary arterial hypertension.", + "The patient refused an initial combination therapy including a parenteral prostacyclin analogue.", + "The patient's refusal was in accordance with the ESC/ERS guidelines.", + "An off-label triple oral combination therapy was started.", + "The triple oral combination therapy included a phosphodiesterase-5 inhibitor.", + "The triple oral combination therapy included an endothelin receptor antagonist.", + "The triple oral combination therapy included selexipag.", + "At 3- and 6-month follow-up, clinical and haemodynamic improvement was found.", + "The patient was reclassified as low risk.", + "Her clinical condition is currently stable." + ] + }, + { + "id": "multiclinsum_test_2833_en.txt", + "fulltext": "A 53-year-old female patient presented with a 10-year history of enlargement of right heart cavities with mild elevation of pulmonary artery pressure and mild dyspnoea. Her baseline electrocardiogram showed normal sinus rhythm with incomplete right bundle branch block, cardiac auscultation revealed a fixed split S2. First echocardiographic cue of the congenital disease was a partial reverse flow of the RUPV and evidence of relevant left-to-right shunt at the level of the SVC , as assessed by transoesophageal echocardiography. Her past medical history includes dyslipidaemia, arterial hypertension and anxiety disorder.\nCardiac magnetic resonance imaging (CMR) confirmed right heart dilatation with normal biventricular function and showed dilatation of the pulmonary trunk (38 mm). 3D magnetic resonance angiography (Golden-angle RAdial Sparse Parallel MRI) demonstrated a large side-to-side communication (cavopulmonary window) of the RUPV with SVC of 19 mm resulting in isolated PAPVR. The RUPV retained its connection to the LA and as a result forming a PAPV drainage.\nFlow measurements were done of the ascending, and descending aorta, as well as pulmonary artery (not shown) and showed a significant left-to-right shunt with Qp:Qs of 1.6. Approximate (no axial correction) net forward flow in the SVC distal to the cavopulmonary window was markedly elevated (113 mL). It was much higher than the usually expected backflow from head and upper extremities (difference of net forward flow of ascending and descending aorta: 96 mL − 63 mL = 33 mL) and further confirmed significant left-to-right shunting.\nAt right heart catheterization, the anomalous connection of the RUPV to the SVC was confirmed by a jump in the oxygen saturation of the SVC proximal to the cavopulmonary window of 76–96% at the level of the cavopulmonary window. Angiographically, there was evidence of significant left-to-right shunting with a Qp:Qs of 2.2.\nGiven the haemodynamic significance of this patient’s shunt, right cavity dilatation, and mild elevation of pulmonary artery pressure the defect has been repaired using minimally invasive axillary thoracotomy . An atrial tunnel patch was inserted through a patent foramen ovale (PFO) to redirect flow from the RUPV to the LA .\nIn a follow-up CMR 7 months after the operation, it could be demonstrated that the cavopulmonary window was closed with unchanged normal connection of the RUPV to the LA. Yet, there was evidence of a post-operative interatrial shunt (Qp:Qs = 1.2) in proximity to the ostium of the inferior vena cava. Right ventricular end-diastolic volume (RV EDV) was in the upper normal range (RV EDV indexed 106 mL/m2).", + "fulltext_subclaims": [ + "The patient is a 53-year-old female.", + "She had a 10-year history of enlargement of right heart cavities.", + "She had mild elevation of pulmonary artery pressure.", + "She had mild dyspnoea.", + "Her baseline electrocardiogram showed normal sinus rhythm.", + "Her baseline electrocardiogram showed incomplete right bundle branch block.", + "Cardiac auscultation revealed a fixed split S2.", + "The first echocardiographic cue of the congenital disease was a partial reverse flow of the RUPV.", + "There was evidence of a relevant left-to-right shunt at the level of the SVC.", + "The evidence of the left-to-right shunt was assessed by transoesophageal echocardiography.", + "Her past medical history includes dyslipidaemia.", + "Her past medical history includes arterial hypertension.", + "Her past medical history includes anxiety disorder.", + "Cardiac magnetic resonance imaging confirmed right heart dilatation.", + "Cardiac magnetic resonance imaging showed normal biventricular function.", + "Cardiac magnetic resonance imaging showed dilatation of the pulmonary trunk (38 mm).", + "3D magnetic resonance angiography demonstrated a large side-to-side communication (cavopulmonary window) of the RUPV with SVC of 19 mm.", + "The cavopulmonary window resulted in isolated PAPVR.", + "The RUPV retained its connection to the LA.", + "The RUPV formed a PAPV drainage.", + "Flow measurements were done of the ascending aorta.", + "Flow measurements were done of the descending aorta.", + "Flow measurements were done of the pulmonary artery.", + "The flow measurements showed a significant left-to-right shunt with Qp:Qs of 1.6.", + "The net forward flow in the SVC distal to the cavopulmonary window was markedly elevated (113 mL).", + "The net forward flow in the SVC was much higher than the usually expected backflow from head and upper extremities.", + "The difference of net forward flow of ascending and descending aorta was 96 mL − 63 mL = 33 mL.", + "The difference further confirmed significant left-to-right shunting.", + "At right heart catheterization, the anomalous connection of the RUPV to the SVC was confirmed.", + "There was a jump in the oxygen saturation of the SVC proximal to the cavopulmonary window of 76–96%.", + "Angiographically, there was evidence of significant left-to-right shunting with a Qp:Qs of 2.2.", + "The defect was repaired using minimally invasive axillary thoracotomy.", + "An atrial tunnel patch was inserted through a patent foramen ovale to redirect flow from the RUPV to the LA.", + "In a follow-up CMR 7 months after the operation, the cavopulmonary window was closed.", + "The RUPV retained its normal connection to the LA.", + "There was evidence of a post-operative interatrial shunt (Qp:Qs = 1.2).", + "The post-operative interatrial shunt was in proximity to the ostium of the inferior vena cava.", + "Right ventricular end-diastolic volume (RV EDV) was in the upper normal range.", + "RV EDV indexed was 106 mL/m2." + ], + "summary": "We present a case of this unusual variant of a sinus venosus defect far from the atrial roof. Haemodynamic significance of the shunt was confirmed by enlargement of right heart cavities, elevation of pulmonary artery pressure, and significant left-to-right shunting using multimodality cardiac imaging (transoesophageal echocardiography, cardiac magnetic resonance imaging, and right heart catheterization). The defect has been successfully repaired using minimally invasive axillary thoracotomy.", + "summary_subclaims": [ + "This is a case of an unusual variant of a sinus venosus defect far from the atrial roof.", + "Haemodynamic significance of the shunt was confirmed.", + "Right heart cavities were enlarged.", + "Pulmonary artery pressure was elevated.", + "Significant left-to-right shunting was observed.", + "Multimodality cardiac imaging was used.", + "Transoesophageal echocardiography was used.", + "Cardiac magnetic resonance imaging was used.", + "Right heart catheterization was used.", + "The defect was successfully repaired.", + "Minimally invasive axillary thoracotomy was used." + ] + }, + { + "id": "multiclinsum_test_3390_en.txt", + "fulltext": "Female, 50 years old, admitted for dyspnoea associated with a week-long history of antiphospholipid syndrome, lymphoma B-type of parotid gland (free of disease), SARSCoV-2 mild, resolved without need for admission, and placement of a pin and crown three weeks prior to consultation. The patient did not report allergies or intolerances to any medication. She was using acenocoumarol 2 mg daily and clonazepam 2 mg at night. On physical examination, she was lucid, saturation 93% ambient air with correction to 98% with oxygen cannula of 2 liters per minute, tachycardia (heart rate = 120 beats/minute), no tachypnoea (respiratory rate = 18 respiratory cycles/minute). Good ventilatory mechanics with hypoventilation in the left lung. She was admitted to the general admission ward for diagnosis and treatment. Blood cultures were taken and were positive for Staphylococcus aureus sensitive to methicillin (SAMS). A chest X-ray was requested and showed bilateral pleural effusion with a predominant left side. A thoracentesis was performed and a pleural effusion was found with 6 mm vegetation on the mitral valve. Antibiotic treatment with cefazolin 2 g every 8 hours was initiated. She required pulmonary decortication and laminectomy plus drainage of a bilateral pleural effusion. After 48 hours of initiating treatment with cefazolin, a gradual decrease in platelets, leukocytes and red blood cells was observed without apparent clinical repercussion. On day 14 of treatment, she presented with a tricytopenia (leukocytes = 2400/µl, haemocrit = 26%, platelets = 106 000/µl), so a peripheral blood smear was performed that did not show immature elements. The temporal evolution of the blood series was observed, and on day 19, a marked tricytopenia was found. Given the existence of publications that describe cytopenia secondary to cephalosporins6, cefazolin was discontinued and it was decided to continue treatment with vancomycin 1 g every 12 hours. However, it had to be discontinued 48 hours later due to acute renal injury (glomerular filtration rate - GFR = 39.8 ml/min/1.73m2 for a previous value of 217 ml/min/1.73m2). Antibiotic treatment with daptomycin 10 mg/kg/day was initiated. After seven days of initiating the same, the CPK control value was 70 488 U/L (previous value = 105 U/L). At that time, renal function had improved with creatinemia of 0.98 mg/dL and GFR of 60.1 ml/min/1.73m2. Although the patient did not present myopathy symptoms or new renal impairment, it was decided to rotate daptomycin to linezolid 600 mg every 12 hours orally. Two days after initiating said antibiotic, a change in the hepatic panel was observed with elevation of hepatic transaminases (GOT = 698 U/L and GPT = 296 U/L) from previous normal values (GOT = 14 U/L and GPT = 6 U/L). Cefazolin was discontinued due to hepatoxicity associated with it. After two days without active antibiotic treatment, an improvement in the hepatic panel was observed (GOT = 171 U/L, GPT = 180 U/L) and, due to clinical stability, the patient was discharged with a cotrimoxazole 160/800 mg indication every 8 hours orally as an outpatient treatment and control by external consultations with the objective of completing 8 effective weeks of antibiotic treatment. After 12 days of discharge and still on active antibiotic treatment, the patient attended the hospital after falling from her own height with a traumatic encephalocranium, without loss of consciousness. A subdural haematoma was observed in a brain tomography and thrombocytopenia was detected in the laboratory (3000/µl) associated with leucopenia (leucocytes = 900/µl), so it was decided to re-admit the patient. Considering her background, having overcome the cytopenias associated with cefazolin and the chronology of findings, it was interpreted that the bicytopenia could be due to cotrimoxazole treatment, so it was discontinued. In Table 1, the laboratory parameters associated with the different treatments are detailed for each admission. Finally, once the subdural haematoma was resolved and the laboratory findings improved, the patient was discharged from the second admission with antibiotic treatment with clindamycin 600 mg every 12 hours orally, being able to resolve the endocarditis without new RAM. In all cases, drug interactions that could explain what was observed were discarded, and RAM was reported to the national pharmacovigilance system.\n", + "fulltext_subclaims": [ + "The patient is a 50-year-old woman.", + "She was admitted for dyspnoea.", + "She had a week-long history of antiphospholipid syndrome.", + "She had lymphoma B-type of the parotid gland, free of disease.", + "She had a mild SARS-CoV-2 infection that resolved without admission.", + "She had a pin and crown placed three weeks prior to consultation.", + "She did not report allergies or intolerances to any medication.", + "She was using acenocoumarol 2 mg daily.", + "She was using clonazepam 2 mg at night.", + "On physical examination, she was lucid.", + "Her oxygen saturation was 93% on ambient air.", + "Her oxygen saturation improved to 98% with an oxygen cannula at 2 liters per minute.", + "She had tachycardia with a heart rate of 120 beats per minute.", + "She did not have tachypnoea with a respiratory rate of 18 cycles per minute.", + "She was admitted to the general admission ward.", + "Blood cultures were positive for Staphylococcus aureus sensitive to methicillin.", + "A chest X-ray showed bilateral pleural effusion with a predominant left side.", + "A thoracentesis was performed.", + "A 6 mm vegetation was found on the mitral valve.", + "Antibiotic treatment with cefazolin 2 g every 8 hours was initiated.", + "She required pulmonary decortication and laminectomy plus drainage of bilateral pleural effusion.", + "After 48 hours of cefazolin, a gradual decrease in platelets, leukocytes, and red blood cells was observed.", + "On day 14 of treatment, she had tricytopenia.", + "A peripheral blood smear did not show immature elements.", + "On day 19, marked tricytopenia was found.", + "Cefazolin was discontinued due to publications describing cytopenia secondary to cephalosporins.", + "Vancomycin 1 g every 12 hours was initiated.", + "Vancomycin was discontinued 48 hours later due to acute renal injury.", + "Daptomycin 10 mg/kg/day was initiated.", + "After seven days of daptomycin, CPK was 70,488 U/L.", + "Renal function improved with creatinemia of 0.98 mg/dL.", + "Daptomycin was rotated to linezolid 600 mg every 12 hours orally.", + "Two days after linezolid, hepatic transaminases were elevated.", + "Cefazolin was discontinued due to hepatoxicity.", + "After two days without active antibiotic treatment, hepatic panel improved.", + "The patient was discharged with cotrimoxazole 160/800 mg every 8 hours orally.", + "After 12 days of discharge, she attended the hospital after a fall.", + "A subdural haematoma was observed on brain tomography.", + "Thrombocytopenia was detected with platelets of 3000/µl.", + "Leucopenia was detected with leucocytes of 900/µl.", + "Cotrimoxazole was discontinued due to suspected bicytopenia.", + "The patient was re-admitted.", + "She was discharged with clindamycin 600 mg every 12 hours orally.", + "RAM was reported to the national pharmacovigilance system." + ], + "summary": "A woman with a diagnosis of endocarditis due to multi-resistant Staphylococcus aureus was described with adverse reactions to five structurally unrelated antibiotics with different mechanisms of action in two consecutive hospitalizations. The reactions were secondary to cefazolin (thrombocytopenia), vancomycin (renal injury), daptomycin (elevation of creatine phosphokinase) and linezolid (hepatotoxicity) in the first hospitalization, and cotrimoxazole (thrombocytopenia) in the second. In all cases, transient damage was observed in different organ systems. Finally, she was discharged with clindamycin without new intercurrences until the end of treatment.\n", + "summary_subclaims": [ + "The patient had a diagnosis of endocarditis due to multi-resistant Staphylococcus aureus.", + "The patient had adverse reactions to five structurally unrelated antibiotics with different mechanisms of action in two consecutive hospitalizations.", + "The first hospitalization included an adverse reaction to cefazolin with thrombocytopenia.", + "The first hospitalization included an adverse reaction to vancomycin with renal injury.", + "The first hospitalization included an adverse reaction to daptomycin with elevation of creatine phosphokinase.", + "The first hospitalization included an adverse reaction to linezolid with hepatotoxicity.", + "The second hospitalization included an adverse reaction to cotrimoxazole with thrombocytopenia.", + "In all cases, transient damage was observed in different organ systems.", + "The patient was discharged with clindamycin.", + "There were no new intercurrences until the end of treatment." + ] + }, + { + "id": "multiclinsum_test_2938_en.txt", + "fulltext": "A 53-year-old Japanese woman was admitted to Niigata Rheumatic Centre, Shibata city, Japan. She had been diagnosed with MS associated with right optic neuritis and thoracic myelitis when she was 25 years old and treated with high-dose prednisolone (PSL). The myelitis had relapsed three times when she was 36, 37 and 40 years old and treated with high-dose PSL. Oligoclonal IgG band was found in cerebral spinal fluid (CSF) and IgG and myelin basic protein in CSF were elevated (4.9 mg/dL and 1.2 mg/dL, respectively). Brain T2 weighted magnetic resonance imaging (MRI) showed high intensity area beside left lateral ventricle indicating asymptomatic plaque lesion due to MS. High intensity area was also shown in T2 weighted MRI of cervical spinal cord. Anti-aquaporin 4 antibody was negative. Slight right hemiparesis remained, and she needed a cane to walk outside. The MS achieved remission and PSL was stopped for 9 years. When she was 50 years old, polyarthritis developed, and rheumatoid factor and C-reactive protein (CRP) levels were high. She was diagnosed with RA. The PSL was restarted at 7.5 mg daily and methotrexate (MTX) was begun. Because the MTX could not be increased over 8 mg/week because of mild elevation of transaminases, tacrolimus (3 mg daily; TAC) was added to MTX and leukocyte apheresis was performed. However, the RA activity remained high: the CRP was 2.3 mg/dL and the disease activity score (DAS28ESR) was 4.94 (moderate disease activity). Furthermore, joint space narrowing of both knees and ankles had progressed obviously over 1 year. Because anti-TNF therapy can exacerbate demyelinating disease, the anti-IL-6 receptor antibody tocilizumab (TCZ) was started at 8 mg/kg every 4 weeks. At the second administration of TCZ, the CRP was <0.1 mg/dL and the DAS28ESR was 2.0 (complete remission). The MTX and TAC were tapered and stopped in 6 months, and the PSL was tapered to 0.5 mg daily in 1 year. The health assessment questionnaire disability index (HAQ DI) in 1 year was 1.88 and functional disability was remained. At the 5-year follow-up, she remained in remission with TCZ.\nSerum interferon (IFN) -γ was negative (≤0.1 IU/mL) and serum high sensitivity TNF-α was within normal range (1.6 pg/mL) before starting TCZ therapy. Both of them kept the same levels for a year. Serum IL-6 level was elevated, 51.2 pg/mL (normal range; ≤4.0 pg/mL) before starting TCZ therapy and it was 57.1 pg/mL a year later.", + "fulltext_subclaims": [ + "The patient was a 53-year-old Japanese woman.", + "She was admitted to Niigata Rheumatic Centre, Shibata city, Japan.", + "She had been diagnosed with MS associated with right optic neuritis and thoracic myelitis when she was 25 years old.", + "She had been treated with high-dose prednisolone (PSL).", + "The myelitis had relapsed three times when she was 36, 37, and 40 years old.", + "Oligoclonal IgG band was found in cerebral spinal fluid (CSF).", + "IgG in CSF was elevated to 4.9 mg/dL.", + "Myelin basic protein in CSF was elevated to 1.2 mg/dL.", + "Brain T2 weighted MRI showed high intensity area beside left lateral ventricle.", + "The high intensity area in MRI was indicating asymptomatic plaque lesion due to MS.", + "High intensity area was also shown in T2 weighted MRI of cervical spinal cord.", + "Anti-aquaporin 4 antibody was negative.", + "Slight right hemiparesis remained.", + "She needed a cane to walk outside.", + "The MS achieved remission.", + "PSL was stopped for 9 years.", + "When she was 50 years old, polyarthritis developed.", + "Rheumatoid factor levels were high.", + "C-reactive protein (CRP) levels were high.", + "She was diagnosed with RA.", + "PSL was restarted at 7.5 mg daily.", + "Methotrexate (MTX) was begun.", + "MTX could not be increased over 8 mg/week because of mild elevation of transaminases.", + "Tacrolimus (3 mg daily; TAC) was added to MTX.", + "Leukocyte apheresis was performed.", + "RA activity remained high.", + "CRP was 2.3 mg/dL.", + "DAS28ESR was 4.94.", + "Joint space narrowing of both knees and ankles had progressed obviously over 1 year.", + "Tocilizumab (TCZ) was started at 8 mg/kg every 4 weeks.", + "At the second administration of TCZ, CRP was <0.1 mg/dL.", + "At the second administration of TCZ, DAS28ESR was 2.0.", + "MTX and TAC were tapered and stopped in 6 months.", + "PSL was tapered to 0.5 mg daily in 1 year.", + "HAQ DI in 1 year was 1.88.", + "Functional disability was remained.", + "At the 5-year follow-up, she remained in remission with TCZ.", + "Serum interferon (IFN)-γ was negative (≤0.1 IU/mL) before starting TCZ therapy.", + "Serum high sensitivity TNF-α was within normal range (1.6 pg/mL) before starting TCZ therapy.", + "Serum IL-6 level was elevated, 51.2 pg/mL before starting TCZ therapy.", + "Serum IL-6 level was 57.1 pg/mL a year later." + ], + "summary": "A 53-year-old Japanese woman with multiple sclerosis and rheumatoid arthritis was admitted to our hospital because her rheumatoid arthritis was uncontrolled with oral methotrexate, tacrolimus, and prednisolone. She had developed multiple sclerosis when she was 25 years old and was treated with glucocorticoid therapy. Her multiple sclerosis was in remission for more than 9 years. Because anti-tumour necrosis factor therapy can exacerbate demyelinating disease, the anti-interleukin-6 receptor antibody tocilizumab was started at 8 mg/kg every 4 weeks. At the second administration of tocilizumab, complete remission was achieved. She has remained in remission with tocilizumab without recurrence of multiple sclerosis for more than 5 years.", + "summary_subclaims": [ + "A 53-year-old Japanese woman with multiple sclerosis and rheumatoid arthritis was admitted to our hospital.", + "Her rheumatoid arthritis was uncontrolled with oral methotrexate, tacrolimus, and prednisolone.", + "She had developed multiple sclerosis when she was 25 years old.", + "Her multiple sclerosis was treated with glucocorticoid therapy.", + "Her multiple sclerosis was in remission for more than 9 years.", + "Anti-tumour necrosis factor therapy can exacerbate demyelinating disease.", + "The anti-interleukin-6 receptor antibody tocilizumab was started at 8 mg/kg every 4 weeks.", + "At the second administration of tocilizumab, complete remission was achieved.", + "She has remained in remission with tocilizumab without recurrence of multiple sclerosis for more than 5 years." + ] + }, + { + "id": "multiclinsum_test_1680_en.txt", + "fulltext": "A 83-year-old hypertensive man presented to the Emergency Department for dizziness and hypotension. He was treated by β-blockers (bisoprolol), diuretics (hydrochlorothiazide), ACE inhibitors (valsartan) and platelet inhibitors (lysine acetylsalicylate) for hypertension and arythmia. The patient denied any thoracic pain or recent trauma. Upon admission, blood pressure was 60/40 mmHg on both arms, and hypotension persisted despite a fluid loading of 2.5 L. A vasopressor support was promptly initiated (norepinephrin: 1,2 μg/kg/min). A bradycardia (54 bpm) with decreased cardiac sounds and distended jugular veins were noted. The patient had oliguria and mottled skin. A severe metabolic acidosis was observed (pH: 7.31; BD: -10.4 mmol/L; lactate: 6.76 mmol/L). ALAT level was moderately increased (62 UI/L) without increase in bilirubin or troponin. The electrocardiogram recorded a normal sinus rhythm with an incomplete left bundle branch block. Transthoracic echocardiography disclosed a circumferential pericardial effusion with a compressed right atrium and increased respiratory variations of tricuspidal mitral Doppler velocities. Left ventricular systolic function was normal, without regional wall motion abnormality. Contrast-enhanced thoracic CT scan ruled out an acute dissection of the ascending aorta and confirmed the presence of the circumferential pericardial effusion . A pig-tail catheter was placed within the pericardial sac using the subcostal approach under echocardiographic guidance. There were withdrawn 500 ml of blood, which resulted in a transient improvement of hemodynamics. Rapidly, hypotension resumed despite increasing doses of Norepinephrine (up to 0,7 μg/kg/min) and the pericardial drainage remained productive (450 ml/hour of fresh blood). This prompted a reoperation under extracorporeal circulation. The surgeon confirmed the presence of a hemopericardium with numerous clots in the dependent region of the pericardial sac. An active bleeding was identified at the level of the retroventricular coronary artery and of the epicardial surface which was related to a superficial laceration of the posterolateral wall of the left ventricle. The pericardium was thickened with several \"sharping\" calcified plaques in the vicinity of the bleeding areas. Hemostatic patches were placed and the posterior aspect of the pericardium was resected and replaced by a pericardial patch. The postoperative course was uneventful. On day 2, vasopressors were stopped and the patient was successfully extubated. The pathologic examination of pericardial plaques disclosed a calcified pericardium without specific tumoral infiltration or inflammatory process . No any sign of a tuberculosis origin was evidenced. One month later, the patient remained asymptomatic. Final diagnosis was a spontaneous cardiac tamponade secondary to a coronary artery injury attributed to a \"sharping\"calcified pericardial plaque.", + "fulltext_subclaims": [ + "The patient is an 83-year-old man.", + "The patient is hypertensive.", + "The patient presented to the Emergency Department for dizziness and hypotension.", + "The patient was treated by β-blockers (bisoprolol).", + "The patient was treated by diuretics (hydrochlorothiazide).", + "The patient was treated by ACE inhibitors (valsartan).", + "The patient was treated by platelet inhibitors (lysine acetylsalicylate).", + "The patient denied any thoracic pain.", + "The patient denied any recent trauma.", + "Upon admission, blood pressure was 60/40 mmHg on both arms.", + "Hypotension persisted despite a fluid loading of 2.5 L.", + "A vasopressor support was promptly initiated (norepinephrine: 1.2 μg/kg/min).", + "A bradycardia (54 bpm) was noted.", + "Decreased cardiac sounds were noted.", + "Distended jugular veins were noted.", + "The patient had oliguria.", + "The patient had mottled skin.", + "A severe metabolic acidosis was observed (pH: 7.31).", + "A severe metabolic acidosis was observed (base deficit: -10.4 mmol/L).", + "A severe metabolic acidosis was observed (lactate: 6.76 mmol/L).", + "ALAT level was moderately increased (62 UI/L).", + "There was no increase in bilirubin.", + "There was no increase in troponin.", + "The electrocardiogram recorded a normal sinus rhythm.", + "The electrocardiogram recorded an incomplete left bundle branch block.", + "Transthoracic echocardiography disclosed a circumferential pericardial effusion.", + "Transthoracic echocardiography disclosed a compressed right atrium.", + "Contrast-enhanced thoracic CT scan ruled out an acute dissection of the ascending aorta.", + "Contrast-enhanced thoracic CT scan confirmed the presence of the circumferential pericardial effusion.", + "A pig-tail catheter was placed within the pericardial sac using the subcostal approach under echocardiographic guidance.", + "500 ml of blood were withdrawn.", + "This resulted in a transient improvement of hemodynamics.", + "Hypotension resumed despite increasing doses of norepinephrine.", + "The pericardial drainage remained productive (450 ml/hour of fresh blood).", + "This prompted a reoperation under extracorporeal circulation.", + "The surgeon confirmed the presence of a hemopericardium with numerous clots.", + "An active bleeding was identified at the level of the retroventricular coronary artery.", + "An active bleeding was identified at the level of the epicardial surface.", + "The bleeding was related to a superficial laceration of the posterolateral wall of the left ventricle.", + "The pericardium was thickened with several 'sharping' calcified plaques.", + "Hemostatic patches were placed.", + "The posterior aspect of the pericardium was resected.", + "The posterior aspect of the pericardium was replaced by a pericardial patch.", + "The postoperative course was uneventful.", + "On day 2, vasopressors were stopped.", + "The patient was successfully extubated.", + "The pathologic examination of pericardial plaques disclosed a calcified pericardium.", + "No tumoral infiltration was evidenced.", + "No inflammatory process was evidenced.", + "No sign of a tuberculosis origin was evidenced.", + "One month later, the patient remained asymptomatic.", + "Final diagnosis was a spontaneous cardiac tamponade secondary to a coronary artery injury.", + "The coronary artery injury was attributed to a 'sharping' calcified pericardial plaque." + ], + "summary": "A 83-year-old hypertensive man presented for dizziness and hypotension. The patient had oliguria and mottled skin. Transthoracic echocardiography disclosed a circumferential pericardial effusion with a compressed right atrium, confirmed by contrast-enhanced thoracic CT scan. A pig-tail catheter allowed to withdraw 500 mL of blood, resulting in a transient improvement of hemodynamics. Rapidly, recurrent hypotension prompted a reoperation. An active bleeding was identified at the level of the retroventricular coronary artery. The pericardium was thickened with several \"sharping\" calcified plaques in the vicinity of the bleeding areas. On day 2, vasopressors were stopped and the patient was successfully extubated. Final diagnosis was a spontaneous cardiac tamponade secondary to a coronary artery injury attributed to a \"sharping\"calcified pericardial plaque.", + "summary_subclaims": [ + "The patient is an 83-year-old man.", + "The patient is hypertensive.", + "The patient presented for dizziness and hypotension.", + "The patient had oliguria.", + "The patient had mottled skin.", + "Transthoracic echocardiography disclosed a circumferential pericardial effusion.", + "Transthoracic echocardiography showed a compressed right atrium.", + "A pig-tail catheter allowed to withdraw 500 mL of blood.", + "The withdrawal of 500 mL of blood resulted in a transient improvement of hemodynamics.", + "Recurrent hypotension prompted a reoperation.", + "An active bleeding was identified at the level of the retroventricular coronary artery.", + "The pericardium was thickened.", + "There were several 'sharping' calcified plaques in the vicinity of the bleeding areas.", + "Vasopressors were stopped on day 2.", + "The patient was successfully extubated on day 2.", + "The final diagnosis was a spontaneous cardiac tamponade.", + "The cardiac tamponade was secondary to a coronary artery injury.", + "The coronary artery injury was attributed to a 'sharping' calcified pericardial plaque." + ] + }, + { + "id": "multiclinsum_test_81_en.txt", + "fulltext": "A 44-year-old Chinese female with left invasive ductal breast cancer underwent a modified radical mastectomy in April 2005. The pathological stage of her cancer was T2N0M0 with intermediate grade and lymphovascular invasion. The primary tumor was ER, PR, and HER2 positive and phosphatase and tensin homologue (PTEN) negative as determined by immunohistochemistry (IHC). The expression of ER and PR was scored according to the Allred score. HER2 status was scored as positive if >30% of tumor cells showed strong (3+) membrane staining, and PTEN status was designated as positive if tumor cells showed positive staining by IHC. The patient was treated with CAF (cyclophosphamide, adriamycin, and fluorouracil) adjuvant chemotherapy for six cycles and tamoxifen for 2 years without radiotherapy or trastuzumab. Metastases to the supraclavicular and cervical lymph nodes and left chest wall relapse were found in December 2007. Thus, the disease-free survival was 32 months.\nFrom December 2007 to August 2012, the patient underwent multiple-line rescue treatments including several cytotoxic agents, HER2-targeted therapies, and endocrine therapies used for breast cancer . Pretreatment biopsy and pathology results were not available. The rescue treatment was started with chemotherapy, but this was switched to endocrine drugs due to the adverse effects of chemotherapy. The patient obtained clinical benefit from endocrine therapy. The recurrent tumor in the left supraclavicular lymph nodes was HR negative by IHC and HER2 positive by fluorescence in situ hybridization detection in two hospitals in May 2009. Then, chemotherapy and HER2-directed therapy as main choices were applied, and endocrine therapy was also used due to the intolerance or lack of response to chemotherapy. Among these regimens, two regimens provided clinical benefit, namely, anastrozole combined with goserelin for 11 months and exemestane plus lapatinib for 7 months during the earlier treatment. In contrast, a total of seven regimens containing trastuzumab and two regimens containing lapatinib all failed .\nAfter discussion of various therapeutic options including palliative care, in 2012, we decided to treat the patient with everolimus (5 mg/d orally) in combination with intramuscular fulvestrant (500 mg once/28 days). The response and side effects of the regimen are shown in . After 6 days, we increased the dose of everolimus to 10 mg/d for 34 days., Measurable lung lesions diminished modestly as observed by computed tomography (CT) examination . The changes in target lesions based on the maximum reduction of the sum of lesion diameters are shown in . Side effects included third-degree stomatitis and liver toxicity and second-degree hematologic toxicity. After discontinuation of everolimus for 10 days, the side effects were relieved and eventually disappeared. When the patient took 5 mg everolimus daily, the lung lesions increased slightly. We therefore increased the dose to 5 and 10 mg/d alternately, with an estimated daily dose of 7.5 mg, and the lesions diminished again. Subsequently, everolimus was reduced to 5 mg daily or treatment was discontinued due to fatigue and other adverse events. Treatment was resumed again at 5 and 10 mg/d alternatively and after approximately six months of treatment, the patient could tolerate the full dose (10 mg/d) of everolimus.\nAt the first appearance of tumor progression detected by CT on June 7, 2013, the patient’s pleural effusion was extracted for pathologic examination and molecular profile testing (performed by Caris Life Sciences, Irving, TX, USA). The results confirmed that the tumor was a HR-negative, HER2-positive adenocarcinoma that contained a PIK3CA gene mutation and was positive for PTEN expression . The patient continued everolimus treatment until disease progression was confirmed on June 24, 2013. The response was stable disease as evaluated by Response evaluation criteria in solid tumors, and progression-free survival (PFS) was 10 months. Thereafter, the patient was treated with trastuzumab, emtansine, and sorafenib, individually, with no measurable responses. The patient died on October 27, 2013, with overall survival time of 102 months. Written informed consent was obtained from the patient for publication of this Case Report and any accompanying images. This case report was approved by the Ethics Committee of Affiliated Hospital of Academy of Military Medical Sciences.", + "fulltext_subclaims": [ + "The patient was a 44-year-old Chinese female.", + "She had left invasive ductal breast cancer.", + "She underwent a modified radical mastectomy in April 2005.", + "The pathological stage was T2N0M0.", + "The tumor was intermediate grade.", + "The tumor showed lymphovascular invasion.", + "The tumor was ER, PR, and HER2 positive.", + "The tumor was PTEN negative as determined by immunohistochemistry.", + "The patient received CAF adjuvant chemotherapy for six cycles.", + "The patient received tamoxifen for 2 years.", + "The patient did not receive radiotherapy.", + "The patient did not receive trastuzumab.", + "Metastases to the supraclavicular and cervical lymph nodes were found in December 2007.", + "Left chest wall relapse was found in December 2007.", + "The disease-free survival was 32 months.", + "The patient underwent multiple-line rescue treatments from December 2007 to August 2012.", + "The recurrent tumor in the left supraclavicular lymph nodes was HR negative by IHC.", + "The recurrent tumor was HER2 positive by fluorescence in situ hybridization detection.", + "The patient obtained clinical benefit from endocrine therapy.", + "Anastrozole combined with goserelin provided clinical benefit for 11 months.", + "Exemestane plus lapatinib provided clinical benefit for 7 months.", + "Two regimens containing trastuzumab failed.", + "Two regimens containing lapatinib failed.", + "The patient was treated with everolimus (5 mg/d orally) in combination with intramuscular fulvestrant.", + "The dose of everolimus was increased to 10 mg/d after 6 days.", + "Measurable lung lesions diminished modestly as observed by CT.", + "Side effects included third-degree stomatitis.", + "Side effects included liver toxicity.", + "Side effects included second-degree hematologic toxicity.", + "After discontinuation of everolimus for 10 days, the side effects were relieved and eventually disappeared.", + "When the patient took 5 mg everolimus daily, the lung lesions increased slightly.", + "The dose of everolimus was increased to 5 and 10 mg/d alternately.", + "The patient could tolerate the full dose (10 mg/d) of everolimus after approximately six months of treatment.", + "Tumor progression was detected by CT on June 7, 2013.", + "The tumor was confirmed as HR-negative, HER2-positive adenocarcinoma.", + "The tumor contained a PIK3CA gene mutation.", + "The tumor was positive for PTEN expression.", + "The patient continued everolimus treatment until disease progression was confirmed on June 24, 2013.", + "The response was stable disease as evaluated by Response evaluation criteria in solid tumors.", + "The progression-free survival was 10 months.", + "The patient was treated with trastuzumab, emtansine, and sorafenib, individually.", + "The patient died on October 27, 2013.", + "The overall survival time was 102 months.", + "Written informed consent was obtained from the patient for publication of this Case Report.", + "This case report was approved by the Ethics Committee of Affiliated Hospital of Academy of Military Medical Sciences." + ], + "summary": "A 44-year-old female was diagnosed with recurrent HER2-positive breast cancer. The primary tumor was HR positive; however, the metastatic tumor was HR negative. The patient was resistant to classical chemotherapeutic agents and anti-HER2 treatment. Thus, the combination of everolimus and fulvestrant, a selective estrogen receptor downregulator, was chosen to reverse the resistance to anti-HER2 therapy. Indeed, the patient experienced long-term disease stabilization. Adverse events associated with the treatment were manageable by dose adjustments. We performed genetic testing of the metastatic tumor, which harbored a PIK3CA gene mutation but was positive for phosphatase and tensin homologue expression, which might result in resistance to the mammalian target of rapamycin inhibitor.", + "summary_subclaims": [ + "The patient was a 44-year-old female.", + "The patient was diagnosed with recurrent HER2-positive breast cancer.", + "The primary tumor was HR positive.", + "The metastatic tumor was HR negative.", + "The patient was resistant to classical chemotherapeutic agents.", + "The patient was resistant to anti-HER2 treatment.", + "The combination of everolimus and fulvestrant was chosen.", + "Fulvestrant is a selective estrogen receptor downregulator.", + "The patient experienced long-term disease stabilization.", + "Adverse events associated with the treatment were manageable by dose adjustments.", + "Genetic testing of the metastatic tumor was performed.", + "The metastatic tumor harbored a PIK3CA gene mutation.", + "The metastatic tumor was positive for phosphatase and tensin homologue expression.", + "The phosphatase and tensin homologue expression might result in resistance to the mammalian target of rapamycin inhibitor." + ] + }, + { + "id": "multiclinsum_test_2542_en.txt", + "fulltext": "This 29-year-old Asian female, who was otherwise in previously good health, presented with recurrent episodes of severe headache, nausea, and vomiting. She described the headache as “pulling” downward, triggered by standing, and resolving when supine. She reported having had axial tension and rotatory manipulation of her neck one week prior to the onset of her symptoms but denied immediate symptoms afterward. She experienced increasingly painful headaches over the 2 weeks following her chiropractic manipulation. She had no known prior history of trauma, dural structural pathology, or connective tissue disease.\nPhysical exam was normal with no neurological deficits. Previous cervical magnetic resonance imaging (MRI) with and without contrast had been unremarkable. Cervical MRI at presentation revealed only a CSF-isodense ventral extradural fluid collection in the lower cervical spine and upper thoracic spine without any mass effect on the thecal sac . There was no meningeal enhancement, perineural cyst, dural ectasia, or abnormal venous engorgement.\nThe patient was managed conservatively with bed rest for 2 weeks and made a complete spontaneous recovery. Follow-up cervical MRI at 6 months demonstrated decreased size of ventral extradural fluid collection . The patient is doing well presently (1 year subsequent to chiropractic procedure).", + "fulltext_subclaims": [ + "The patient is a 29-year-old Asian female.", + "She had previously been in good health.", + "She presented with recurrent episodes of severe headache, nausea, and vomiting.", + "She described the headache as 'pulling' downward.", + "The headache was triggered by standing.", + "The headache resolved when supine.", + "She reported axial tension and rotatory manipulation of her neck one week prior to the onset of her symptoms.", + "She denied immediate symptoms after the chiropractic manipulation.", + "She experienced increasingly painful headaches over the 2 weeks following her chiropractic manipulation.", + "She had no known prior history of trauma.", + "She had no known prior history of dural structural pathology.", + "She had no known prior history of connective tissue disease.", + "Physical exam was normal with no neurological deficits.", + "Previous cervical MRI with and without contrast had been unremarkable.", + "Cervical MRI at presentation revealed a CSF-isodense ventral extradural fluid collection in the lower cervical spine and upper thoracic spine.", + "There was no mass effect on the thecal sac.", + "There was no meningeal enhancement.", + "There was no perineural cyst.", + "There was no dural ectasia.", + "There was no abnormal venous engorgement.", + "The patient was managed conservatively with bed rest for 2 weeks.", + "She made a complete spontaneous recovery.", + "Follow-up cervical MRI at 6 months demonstrated decreased size of ventral extradural fluid collection.", + "The patient is doing well presently." + ], + "summary": "We present a case of subacute cervical cerebrospinal fluid (CSF) leak resulting from chiropractic manipulation of the cervical spine. The patient is a 29-year-old female who received manipulation one week prior to developing symptoms of severe orthostatic headache, nausea, and vomiting. Magnetic resonance imaging (MRI) revealed a new C5-C6 ventral CSF collection. Symptomatic onset corresponded with the recent cervical chiropractic adjustment. We present serial imaging correlating with her symptomatology and review the pertinent literature on complications of chiropractic manipulation.", + "summary_subclaims": [ + "We present a case of subacute cervical cerebrospinal fluid (CSF) leak resulting from chiropractic manipulation of the cervical spine.", + "The patient is a 29-year-old female.", + "The patient received manipulation one week prior to developing symptoms.", + "The patient developed symptoms of severe orthostatic headache, nausea, and vomiting.", + "Magnetic resonance imaging (MRI) revealed a new C5-C6 ventral CSF collection.", + "Symptomatic onset corresponded with the recent cervical chiropractic adjustment.", + "We present serial imaging correlating with her symptomatology.", + "We review the pertinent literature on complications of chiropractic manipulation." + ] + }, + { + "id": "multiclinsum_test_293_en.txt", + "fulltext": "A 56-year-old woman with no history of smoking was admitted to the respiratory department of our hospital on April 24, 2022, with a history of cough and dyspnea over the past six months. Chest computed tomography revealed a massive right hydrothorax. The patient underwent thoracocentesis, and pleural fluid tumor markers, including carcinoembryonic antigen (CEA), cytokeratin 21-1 fragment, and carbohydrate antigen 19-9 (CA199) were significantly elevated. A reexamination of chest CT after pleural effusion drainage demonstrated a hilar mass accompanied multiple nodules in both lungs. Subsequently, tracheoscopy was performed, which unveiled neoplasm in the medial segment of the middle lobe of the right lung . The pathological diagnosis was adenocarcinoma, and immunohistochemical analysis showed that the tumor cells were positive for CK7, NapsinA, ALK, and TTF-1 . The following next-generation sequencing (NGS) analysis (Yunying Medical Inspection Institute) confirmed that the intergenic region (chr2: 30,193,816)-ALK fusion (with an abundance of 8.10%) was positive , suggesting may be benefit from the treatment of Alectinib or Crizotinib. We prescribed Alectinib for the patient, and the dose was 600 mg two times per day. Reexamination after three months showed an obvious decrease of the hilar mass and other nodules, no recurrence of pleural effusion . The patient had no apparent side effect after therapy but a slight abnormal liver function in first two weeks.", + "fulltext_subclaims": [ + "The patient is a 56-year-old woman.", + "The patient had no history of smoking.", + "The patient was admitted to the respiratory department of the hospital on April 24, 2022.", + "The patient had a history of cough and dyspnea over the past six months.", + "Chest computed tomography revealed a massive right hydrothorax.", + "The patient underwent thoracocentesis.", + "Pleural fluid tumor markers were significantly elevated.", + "A reexamination of chest CT after pleural effusion drainage demonstrated a hilar mass.", + "The CT reexamination showed multiple nodules in both lungs.", + "Tracheoscopy was performed.", + "Tracheoscopy unveiled neoplasm in the medial segment of the middle lobe of the right lung.", + "The pathological diagnosis was adenocarcinoma.", + "The tumor cells were positive for CK7.", + "The tumor cells were positive for NapsinA.", + "The tumor cells were positive for ALK.", + "The tumor cells were positive for TTF-1.", + "Next-generation sequencing analysis confirmed the intergenic region (chr2: 30,193,816)-ALK fusion was positive.", + "The ALK fusion had an abundance of 8.10%.", + "The NGS analysis was performed by Yunying Medical Inspection Institute.", + "The patient was prescribed Alectinib.", + "The dose of Alectinib was 600 mg two times per day.", + "Reexamination after three months showed an obvious decrease of the hilar mass.", + "Reexamination after three months showed an obvious decrease of other nodules.", + "There was no recurrence of pleural effusion.", + "The patient had no apparent side effect after therapy.", + "The patient had a slight abnormal liver function in the first two weeks." + ], + "summary": "A 56-year-old female patient who had symptoms of persistent cough and shortness of breath visited our facility on April 24, 2022. The chest computerized tomography (CT) examination revealed a massive right hydrothorax. After draining pleural effusion, a hilar mass accompanied multiple nodules in both lungs could been seen in image. Tracheoscopy revealed neoplasm in the medial segment of the middle lobe of the right lung, and the patient was diagnosed as lung adenocarcinoma pathologically. It tested positive for cytokeratin (CK) 7, NapsinA, ALK, and thyroid transcription factor-1 (TTF-1). Next generation sequence testing confirmed the presence of the intergenic region (chr2: 30,193,816)-ALK fusion in the tumor tissue. The patient was subsequently treated with Alectinib, and her symptoms are obviously relieved, the right hilar mass and metastatic nodule were reduced in the reexamination after three months.", + "summary_subclaims": [ + "The patient is a 56-year-old female.", + "The patient had symptoms of persistent cough and shortness of breath.", + "The patient visited the facility on April 24, 2022.", + "A chest CT examination revealed a massive right hydrothorax.", + "After draining pleural effusion, a hilar mass accompanied multiple nodules in both lungs could be seen in the image.", + "Tracheoscopy revealed neoplasm in the medial segment of the middle lobe of the right lung.", + "The patient was diagnosed as lung adenocarcinoma pathologically.", + "The tumor tested positive for cytokeratin (CK) 7.", + "The tumor tested positive for NapsinA.", + "The tumor tested positive for ALK.", + "The tumor tested positive for thyroid transcription factor-1 (TTF-1).", + "Next generation sequence testing confirmed the presence of the intergenic region (chr2: 30,193,816)-ALK fusion in the tumor tissue.", + "The patient was treated with Alectinib.", + "The patient's symptoms are obviously relieved.", + "The right hilar mass and metastatic nodule were reduced in the reexamination after three months." + ] + }, + { + "id": "multiclinsum_test_2391_en.txt", + "fulltext": "A 72-year-old woman presented with complaints of constipation for three months. Physical examination, haematological and biochemical investigations were normal. Medical history was unremarkable. A colonoscopy was performed and revealed a sessile polypoid lesion of 5 mm of the sigmoid colon. The polyp had a smooth surface, without nodularity or ulceration . Histopathological examination of the biopsy showed a submucosal lymphoid infiltrate with follicular architecture , characterized by large centroblasts with few, centrocytes . Immunohistochemistry showed that the lymphoid cells were positive for CD20, CD10, BCL6, BCL2, and MYC protein expression with remnants of the FDC meshwork highlighted by CD21 staining and high proliferation index (Ki-67: 60–70%) (not shown) . Fluorescent in-situ hybridization (FISH) studies (probes: Vysis LSI MYC Dual Color Break Apart Rearrangement Probe; Vysis LSI BCL2 Dual Color Break Apart FISH Probe; Abbott, Chicago, Illinois) detected both IGH/BCL2 and IGH/MYC gene rearrangements in approximately 60% of interphase nuclei . No evidence of BCL6 gene rearrangement was found (probe: Vysis LSI BCL6 Dual Color Break Apart Rearrangement Probe; Abbott). The diagnosis of an extra-nodal follicular lymphoma grade 3A with BCL2 and MYC rearrangements was made (DH-FL). The patient underwent a complete clinical staging with FDG-PET/CT and bone marrow biopsy. No signs of disseminated disease were found and primary colonic localization was confirmed. Although bearing molecular hallmarks of malignancy, a watch-and-wait approach was adopted according to the clinically favourable setting. The patient, after two years of follow-up shows no signs of relapse.", + "fulltext_subclaims": [ + "The patient is a 72-year-old woman.", + "She had complaints of constipation for three months.", + "Physical examination was normal.", + "Haematological and biochemical investigations were normal.", + "Medical history was unremarkable.", + "A colonoscopy was performed.", + "A sessile polypoid lesion of 5 mm was found in the sigmoid colon.", + "The polyp had a smooth surface.", + "The polyp showed no nodularity.", + "The polyp showed no ulceration.", + "Histopathological examination showed a submucosal lymphoid infiltrate with follicular architecture.", + "The lymphoid infiltrate was characterized by large centroblasts with few centrocytes.", + "The lymphoid cells were positive for CD20.", + "The lymphoid cells were positive for CD10.", + "The lymphoid cells were positive for BCL6.", + "The lymphoid cells were positive for BCL2.", + "The lymphoid cells were positive for MYC protein expression.", + "The FDC meshwork was highlighted by CD21 staining.", + "The proliferation index (Ki-67) was 60–70%.", + "FISH studies detected IGH/BCL2 gene rearrangements in approximately 60% of interphase nuclei.", + "FISH studies detected IGH/MYC gene rearrangements in approximately 60% of interphase nuclei.", + "No evidence of BCL6 gene rearrangement was found.", + "The diagnosis was extra-nodal follicular lymphoma grade 3A with BCL2 and MYC rearrangements.", + "The patient underwent FDG-PET/CT.", + "The patient underwent bone marrow biopsy.", + "No signs of disseminated disease were found.", + "Primary colonic localization was confirmed.", + "A watch-and-wait approach was adopted.", + "The patient showed no signs of relapse after two years of follow-up." + ], + "summary": "A 72-year-old woman presents with constipation. Colonoscopy reveals a sessile polypoid lesion of the colon bearing morphological, immunohistochemical and molecular hallmarks of DH-FL. Complete clinical staging and bone marrow biopsy showed no signs of disseminated disease. The patient, after two years of follow-up is still free of disease confirming the indolent behaviour of this limited lesion.", + "summary_subclaims": [ + "The patient is a 72-year-old woman.", + "The patient presents with constipation.", + "Colonoscopy reveals a sessile polypoid lesion of the colon.", + "The lesion bears morphological, immunohistochemical and molecular hallmarks of DH-FL.", + "Complete clinical staging showed no signs of disseminated disease.", + "Bone marrow biopsy showed no signs of disseminated disease.", + "The patient is still free of disease after two years of follow-up.", + "The two years of follow-up confirms the indolent behaviour of this limited lesion." + ] + }, + { + "id": "multiclinsum_test_885_en.txt", + "fulltext": "A 44-year-old man was admitted presented to the emergency department with a complaint of right limb weakness and unclear speech for the past 10 h. Questioning medical history, he had also repeated fever and was diagnosed diabetes for one month before admission. At the time of physical examination on admission, the patient was delirious, with fever temperature of 38.8 ℃, muscle strength of the right limb was Grade IV, and other signs were stable. Brain magnetic resonance imaging (MRI) revealed left basal ganglia and right parietal lobe cerebral infarction, which is consistent with embolic stroke .\nLaboratory testing revealed that the blood white cell count was 14.31 × 10^9/L (normal range 3.5–9.5 × 10^9/L), absolute value of neutrophils was 11.16 × 10^9/L (normal range 1.8–6.3 × 10^9/L), percentage of neutrophils was 78.10%. Highly sensitive Troponin I increased to 0.08 ng/ml (normal range 0-0.0268ng/ml) and N-terminal pro-B natriuretic peptide increased to 207.9 ng/L (normal range 0-125ng/L). Chest Computed Tomography (CT) showed that the bilateral lung markings were heavier, the pleura was thickened, strip and nodular high-density shadows were visible, the heart was not enlarged, and calcified spots were visible in the aorta and coronary arteries. Transthoracic echocardiography (TTE) showed the aortic valve was bicuspid combined with calcification, moderate regurgitation and a possible paravalvular abscess (increased thickening to 5 mm in the right posterior sinus wall of the aorta) . A 16.4 mm*7.8 mm vegetation can be seen on the right posterior aortic valve. Based on the clinical, laboratory, and echocardiographic findings, the patient was diagnosed infective endocarditis (IE). According to the AHA/ACC guideline for the management of patients with valvular heart disease, delaying valve surgery for at least 4 weeks may be considered for patients with IE and major ischemic stroke if the patient is hemodynamically stable , the patient was prescribed antibiotics with vancomycin 0.5 g per every 6 h. The transesophageal echocardiography (TEE) was performed 10 days later revealed that the vegetation was smaller than before . He had no fever again and no complaints of discomfort and was hemodynamically stable, the blood cultures were negative twice.\nHowever, TEE one month later after cerebral infarction revealed a large periaortic abscess led to formation of an aortic sinus pseudoaneurysm and flows were in from pseudoaneurysm and out to left ventricular combined with moderate mitral valve regurgitation.\nCardiopulmonary bypass and aortic valve replacement surgery via median sternotomy were performed. During the operation, it was confirmed that bicuspid deformity combined with vegetation, an aortic annular abscess eroding into the base of the anterior mitral leaflet making prolapse of mitral valve annulus . Aortic valve vegetations and perivalvular abscesses were completely removed. 5/0 Prolene suture was used to continuously suture bovine pericardium to reconstruct mitral aortic valve fiber connection and fix the anterior mitral valve annulus. The patient underwent mechanical prosthetic valve replacement and annulus reconstruction successfully. The tissue culture of the diseased aortic valve showed no bacterial growth and no pathogenic microorganism was identified. The patient’s condition was stable after operation. He was discharged two weeks later with antibiotics for six-weeks. During the one-month follow-up, the patient felt well, laboratory testing revealed that the blood white cell count and percentage were normal.", + "fulltext_subclaims": [ + "The patient was a 44-year-old man.", + "He presented with right limb weakness and unclear speech for the past 10 h.", + "He had repeated fever.", + "He was diagnosed with diabetes one month before admission.", + "On admission, he was delirious.", + "His temperature was 38.8 ℃.", + "His right limb muscle strength was Grade IV.", + "Brain MRI revealed left basal ganglia and right parietal lobe cerebral infarction.", + "The infarction was consistent with embolic stroke.", + "White cell count was 14.31 × 10^9/L.", + "The normal range for white cell count is 3.5–9.5 × 10^9/L.", + "Highly sensitive Troponin I was 0.08 ng/ml.", + "The normal range for highly sensitive Troponin I is 0-0.0268 ng/ml.", + "Chest CT showed bilateral lung markings were heavier.", + "Transthoracic echocardiography showed the aortic valve was bicuspid combined with calcification.", + "Transthoracic echocardiography showed moderate regurgitation.", + "A 16.4 mm*7.8 mm vegetation was seen on the right posterior aortic valve.", + "The patient was diagnosed with infective endocarditis.", + "According to the AHA/ACC guideline, delaying valve surgery for at least 4 weeks may be considered for patients with IE and major ischemic stroke if hemodynamically stable.", + "The patient was prescribed vancomycin 0.5 g every 6 h.", + "Transesophageal echocardiography 10 days later showed the vegetation was smaller than before.", + "The patient had no fever again.", + "The patient was hemodynamically stable.", + "Blood cultures were negative twice.", + "Transesophageal echocardiography one month later revealed a large periaortic abscess.", + "The abscess led to formation of an aortic sinus pseudoaneurysm.", + "Flows were in from the pseudoaneurysm and out to the left ventricular.", + "Moderate mitral valve regurgitation was present.", + "Cardiopulmonary bypass and aortic valve replacement surgery via median sternotomy were performed.", + "During the operation, bicuspid deformity combined with vegetation was confirmed.", + "An aortic annular abscess eroded into the base of the anterior mitral leaflet.", + "The anterior mitral leaflet prolapsed.", + "Aortic valve vegetations and perivalvular abscesses were completely removed.", + "5/0 Prolene suture was used to continuously suture bovine pericardium.", + "The tissue culture of the diseased aortic valve showed no bacterial growth.", + "No pathogenic microorganism was identified.", + "The patient was discharged two weeks later.", + "He received antibiotics for six weeks.", + "During one-month follow-up, the patient felt well.", + "Laboratory testing revealed that blood white cell count and percentage were normal." + ], + "summary": "A 44-year-old man was admitted due to weakness of his right limbs and unclear speech for 10 h. He had recurrent fevers for 1 month before admission. Transthoracic echocardiography showed a mix-echoic vegetation attached to the bicuspid aortic valve, moderate aortic regurgitation and a possible aortic annular abscess. Blood cultures were negative and empiric antibiotic therapy was begun. The patient did not have fever again and seem to be clinically improved. However, follow-up transesophageal echocardiography revealed a large periaortic abscess led to aortic sinus pseudoaneurysm. The patient underwent mechanical prosthetic valve replacement and annulus reconstruction successfully. Perivalvular abscess may be insidious deterioration in patients who seem to be clinically improved, which requires us to pay more attention.", + "summary_subclaims": [ + "A 44-year-old man was admitted due to weakness of his right limbs and unclear speech for 10 h.", + "He had recurrent fevers for 1 month before admission.", + "Transthoracic echocardiography showed a mix-echoic vegetation attached to the bicuspid aortic valve.", + "Transthoracic echocardiography showed moderate aortic regurgitation.", + "Transthoracic echocardiography showed a possible aortic annular abscess.", + "Blood cultures were negative.", + "Empiric antibiotic therapy was begun.", + "The patient did not have fever again.", + "The patient seem to be clinically improved.", + "Follow-up transesophageal echocardiography revealed a large periaortic abscess led to aortic sinus pseudoaneurysm.", + "The patient underwent mechanical prosthetic valve replacement.", + "The patient underwent annulus reconstruction.", + "Perivalvular abscess may be insidious deterioration in patients who seem to be clinically improved." + ] + }, + { + "id": "multiclinsum_test_974_en.txt", + "fulltext": "A 47-year-old man with a history of hypertension and diabetes mellitus presented to the emergency room with sudden-onset hemiplegic paralysis on the left side, which had persisted for 3 h. Acute cerebral ischemia was confirmed by magnetic resonance imaging (MRI; Fig. A). The patient suffered from hemiparesis, with a score of 2 points according to the National Institutes of Health Stroke Scale (NIHSS), as evaluated by two neurologists.\nHowever, computed tomography (CT) performed before the MRI revealed a subacute SAH ; thus, intravenous thrombolysis with a recombinant tissue plasminogen activator could not be performed. DSA performed after CT and MRI revealed a dissecting aneurysm in the M1 section of the MCA and distal occlusion further along the aneurysm . Based on the DSA images, we postulated that recanalization of the occluded MCA was too high risk. Furthermore, we considered extracranial-intracranial bypass; however, this was declined by the patient and his family. Thus, conservative treatment was administered with dual antiplatelets (100 mg aspirin and 75 mg clopidogrel daily) and lipid-lowering therapy (40 mg atorvastatin calcium tablet daily), without endovascular treatment. We planned to embolize the dissecting aneurysm in the right MCA one week later.\nUnfortunately, the patient experienced more severe neurological deficits within 24 h, resulting in a new NIHSS score of 12 points. Repeated CT scans excluded intracranial hemorrhage or hemorrhagic transformations. Additional cerebral ischemia was detected using diffusion-weighted imaging (DWI) . We continued the conservative therapeutic strategy. Although hypertension and diabetes mellitus were confirmed by biomedical tests, arterial pressure and blood glucose levels were normal. The neurological function of the patient remained stable. All Glasgow Coma Scale and NIHSS scores are presented in Supplementary Data A, and arterial pressure monitoring data are presented in Supplementary Data B.\nOne week later, endovascular treatment was administered to the M1 aneurysm according to the therapeutic procedure. During this procedure, we observed that the dissecting aneurysm had enlarged significantly, with the volume having more than tripled in one week . The endovascular procedure was completed satisfactorily and the patient underwent neurological rehabilitation. We performed a second DSA nine days after the endovascular procedure, which confirmed successful treatment of the MCA aneurysm . A CT scan performed before DSA revealed that the SAH was barely detectable (Supplementary Data ).\nHowever, the patient experienced a severe headache 5 days after the repeat DSA. CT confirmed a new acute SAH . CT angiography was performed immediately, which revealed no evidence of re-rupture of the treated aneurysm or other new aneurysms (Supplementary Data ). To exclude other hemorrhagic cerebral vascular diseases, such as arterial venous malformation and carotid-cavernous sinus fistula, we performed a fourth DSA on the day after the hemorrhage recurrence. The DSA revealed that an enlarging dissecting aneurysm had been detected in the right PCA , which had not been seen previously. In addition, a new SAH was confirmed on CT during DSA . We intended to perform endovascular treatment by trapping the enlarging dissecting aneurysm and parent artery; however, the patient’s family declined further invasive treatment. Thus, we administered conservative treatment to the patient who died two days later. A schematic diagram details the course of the multiple aneurysms and the treatment modality employed in the present case.", + "fulltext_subclaims": [ + "The patient was a 47-year-old man.", + "The patient had a history of hypertension.", + "The patient had a history of diabetes mellitus.", + "The patient presented with sudden-onset hemiplegic paralysis on the left side.", + "The hemiplegic paralysis had persisted for 3 h.", + "Acute cerebral ischemia was confirmed by magnetic resonance imaging.", + "The patient had hemiparesis.", + "The NIHSS score was 2 points.", + "The NIHSS score was evaluated by two neurologists.", + "Computed tomography performed before the MRI revealed a subacute SAH.", + "Intravenous thrombolysis with a recombinant tissue plasminogen activator could not be performed.", + "DSA revealed a dissecting aneurysm in the M1 section of the MCA.", + "DSA revealed distal occlusion further along the aneurysm.", + "Recanalization of the occluded MCA was postulated to be too high risk.", + "Extracranial-intracranial bypass was considered.", + "Extracranial-intracranial bypass was declined by the patient and his family.", + "Conservative treatment was administered.", + "Dual antiplatelets were administered.", + "Lipid-lowering therapy was administered.", + "Endovascular treatment was not performed.", + "The patient experienced more severe neurological deficits within 24 h.", + "The new NIHSS score was 12 points.", + "Repeated CT scans excluded intracranial hemorrhage.", + "Repeated CT scans excluded hemorrhagic transformations.", + "Additional cerebral ischemia was detected using diffusion-weighted imaging.", + "The conservative therapeutic strategy was continued.", + "Hypertension was confirmed by biomedical tests.", + "Diabetes mellitus was confirmed by biomedical tests.", + "Arterial pressure and blood glucose levels were normal.", + "Neurological function remained stable.", + "Endovascular treatment was administered to the M1 aneurysm one week later.", + "The dissecting aneurysm had enlarged significantly.", + "The volume of the aneurysm had more than tripled in one week.", + "The endovascular procedure was completed satisfactorily.", + "The patient underwent neurological rehabilitation.", + "A second DSA was performed nine days after the endovascular procedure.", + "The second DSA confirmed successful treatment of the MCA aneurysm.", + "A CT scan before the second DSA revealed that the SAH was barely detectable.", + "The patient experienced a severe headache 5 days after the repeat DSA.", + "CT confirmed a new acute SAH.", + "CT angiography revealed no evidence of re-rupture of the treated aneurysm.", + "CT angiography revealed no evidence of other new aneurysms.", + "A fourth DSA was performed on the day after the hemorrhage recurrence.", + "The fourth DSA revealed an enlarging dissecting aneurysm in the right PCA.", + "A new SAH was confirmed on CT during DSA.", + "Endovascular treatment by trapping the enlarging dissecting aneurysm and parent artery was intended.", + "The patient’s family declined further invasive treatment.", + "Conservative treatment was administered.", + "The patient died two days later." + ], + "summary": "A 47-year-old man presented with left limb paralysis. Magnetic resonance imaging revealed a cerebral infarction. Digital subtraction angiography (DSA) identified an aneurysm and occlusion in the right middle cerebral artery (MCA). The MCA aneurysm was remarkably enlarged on the eighth day after cerebral ischemia and was treated using endovascular techniques. Two weeks after the endovascular treatment, the patient experienced a severe headache and became comatose, and a subarachnoid re-hemorrhage was confirmed. The fourth DSA revealed an enlarging dissecting aneurysm in the posterior cerebral artery. The patient died without further treatment.", + "summary_subclaims": [ + "The patient was a 47-year-old man.", + "He presented with left limb paralysis.", + "Magnetic resonance imaging revealed a cerebral infarction.", + "Digital subtraction angiography identified an aneurysm and occlusion in the right middle cerebral artery.", + "The MCA aneurysm was remarkably enlarged on the eighth day after cerebral ischemia.", + "The aneurysm was treated using endovascular techniques.", + "Two weeks after the endovascular treatment, the patient experienced a severe headache.", + "The patient became comatose.", + "A subarachnoid re-hemorrhage was confirmed.", + "The fourth DSA revealed an enlarging dissecting aneurysm in the posterior cerebral artery.", + "The patient died without further treatment." + ] + }, + { + "id": "multiclinsum_test_441_en.txt", + "fulltext": "A 78-year-old female was referred as an emergency to the ophthalmology department of the University Hospital Bonn. She reported blurred vision for seven days and loss of visual field as well as photopsia for 2 days. Amaurosis or diplopia were not reported.\nShe had dry cough for 4 months. This was refractory to symptomatic and antibiotic therapy.\nIn the past 5 weeks, the patient reported increasing diffuse thrusting, bilateral pain in the area of the mandible, while opening her mouth and while chewing. In addition, she noted a thrusting pain in her tongue, which initially increased postprandially but soon was present continuously, and led to difficulties in swallowing. The patient also reported weight loss of 4 kg over the past 4 weeks, increasing fatigue and subfebrile body temperatures as well as scalp tenderness. Severe headaches of the temporal area were denied, as well as myalgia and morning stiffness.\nAll symptoms started on the left side, but affected both sides over time.\nExaminations by a dentist, an orthodontist and an otolaryngologist remained without any findings.\nThe patient was alert, orientated and had appropriate affect on clinical examination.\nThe neurological examination remained unremarkable, without dolorous nerve exit points and a negative swinging flashlight test. The tongue appeared normal, with no diversion, swelling or necrosis. Palpation of the temporal arteries was normal.\nChest radiography was without pathologies.\nThe patient reported neither a history of vasoconstrictive medication, nor was there a history of radiotherapy involving any site of the body.\nLaboratory results revealed increased inflammatory markers. C-reactive protein (CRP) was 71 mg/l (reference range, 0 to 5 mg/l) and erythrocyte sedimentation rate was 75 mm/h (reference range, < 30 mm/h).\nOn admission, the best corrected visual acuity was 20/400 in the left and 20/25 in the right eye. Funduscopic examination of the left eye revealed optic disc edema with cotton wool spots along the upper temporal vascular arch. The macula and the retinal blood vessels appeared normal on fundoscopy .\nOptical coherence tomography (OCT) of the left macula was normal and OCT of the optic disc confirmed disc edema in accordance with the clinical appearance. Retinal nerve fibre layer thickness was increased in the superior, temporal and inferior segments and the optic disc showed diffuse leakage (“hot disc”) on fluorescein angiography . Based on these ophthalmological findings, anterior ischemic optical neuropathy (AION) of the left eye was diagnosed.\nFollowing this, the patient was referred to the Department of Rheumatology at the University Hospital Bonn for further evaluation. The patient underwent ultrasound examination of all arteries typically involved in GCA according to OMERACT protocol . A GE Logiq S8 XDclear ultrasound machine with software version R3 manufactured in 2018 was used. For sonographic examination of the axillary, vertebral and carotid arteries, a linear ultrasound probe with a range from 6 to 15 MHz was used, for all other small arteries including the central retinal artery an ultrasound probe with a range from 8 to 18 MHz was applied.\nVascular ultrasound demonstrated a homogeneous, concentric thickening of the intima-media complex, known as halo sign, in several arteries of the head and neck area [, ]. Ultrasound was performed on axillary arteries, vertebral arteries, common carotid arteries, superficial temporal arteries with both frontal and parietal branches, occipital arteries, facial arteries, and due to the lingual pain, also the lingual artery. Vasculitic affection with increased intima-media thickness (IMT) values above published cut-off values was observed in the common superficial temporal arteries on both sides, both frontal and parietal branches (up to 0.49 mm), as well as in the right facial artery (0.59 mm) and right axillary artery (1.09 mm) . A halo sign was also visible in both vertebral arteries. Exact values and the respective cut-off values are depicted in Table .\nFurthermore, due to tongue claudication and lingual pain, the deep lingual artery, which is a branch of the lingual artery, branching from the external carotid artery, was also examined by ultrasound. It displayed a typical vasculitic halo-sign . Vasculitic IMT swelling led to markedly reduced blood flow and visible IMT thickening in B-mode. Peak IMT of the lingual artery was 1.38 mm. There was no occlusion of the lingual artery. This sonographic finding explained the patient´s symptoms of thrusting pain of her tongue.\nIn addition, transocular ultrasound of the central retinal artery was performed on both sides. Retinal artery displayed a systolic flow velocity of 8.2 cm/s on the left eye, and 7.5 cm/s on the right eye. This meant a marked reduction on both eyes, including the asymptomatic right eye. Until now, we have examined 25 healthy individuals with a mean systolic velocity of 14.4 cm/s (SD ± 3.2) of the central retinal artery.\nThe ocular ultrasound findings were in agreement with both the patient’s visual symptoms and the ophthalmological findings mentioned above.\nDiagnosis of GCA was made based on the patient´s symptoms, clinical examination, laboratory results and ultrasound findings, following the EULAR recommendations for imaging in GCA . Therefore, therapy was promptly initiated. Due to the characteristical sonographic findings no biopsy of the superficial temporal artery or any other artery was performed.\nThe patient received an initial daily dose of 500 mg methylprednisolone intravenous for five days followed by a daily dose of 60 mg prednisolone per os, tapered over 26 weeks according to the GIACTA treatment protocol . Furthermore, tocilizumab treatment was initiated with a weekly dose of 162 mg subcutaneously due to the widespread affection of the arterial vascular bed.\nWith treatment symptoms and laboratory markers quickly improved. Jaw claudication and tongue pain resolved within days and did not reoccur. The patient was dismissed five days later in stable clinical condition.\nThree months after dismissal a follow-up examination was performed. The patient was on 9 mg prednisolone per day, 162 mg tocilizumab subcutaneously per week and free of symptoms. CRP was normal. On ultrasound examination a relevant decrease of IMT values could be observed in all affected arteries. IMT of the deep lingual artery had decreased from 1.38 to 0.77 mm. Systolic flow velocities of both central retinal arteries had increased from 8.2 to 21.6 cm/s on the left eye and from 7.5 to 19.1 cm/s on the right eye.\nAt ophthalmological and sonographic follow-up examination 6 months after the patient´s dismissal, best corrected visual acuity increased from 20/400 to 20/40 in the left eye, the right eye was still without pathological finding. Funduscopic examination of the left eye showed a decrease of optic disc edema with a pale optic disc and narrow vessels.\nOCT of the left macula revealed atrophy of inner retinal layers , while OCT of the optic disc confirmed absence of disc edema and a decrease of retinal nerve fibre layer thickness.\nThe patient was on 12.5 mg prednisolone per day and 162 mg tocilizumab subcutaneously per week and free of symptoms. The dose of prednisolone was increased for a short time by an external rheumatologist, due to recurring headaches and CRP-elevation between the follow-up examinations.\nOn ultrasound examination, a further decrease in IMT values could be observed . Flow velocity of both central retinal arteries showed stable values with 19.1 cm/s on the left eye and 17.2 cm/s on the right eye. IMT of the deep lingual artery had decreased from 0.77 to 0.34 mm.\nTherefore, tapering of prednisolone and therapy with tocilizumab was continued following the GIACTA protocol .", + "fulltext_subclaims": [ + "A 78-year-old female was referred as an emergency to the ophthalmology department of the University Hospital Bonn.", + "She reported blurred vision for seven days.", + "She reported loss of visual field for 2 days.", + "She reported photopsia for 2 days.", + "Amaurosis was not reported.", + "Diplopia was not reported.", + "She had dry cough for 4 months.", + "This was refractory to symptomatic and antibiotic therapy.", + "In the past 5 weeks, the patient reported increasing diffuse thrusting, bilateral pain in the area of the mandible.", + "The pain occurred while opening her mouth and while chewing.", + "She noted a thrusting pain in her tongue.", + "The tongue pain initially increased postprandially.", + "The tongue pain soon was present continuously.", + "The patient reported weight loss of 4 kg over the past 4 weeks.", + "The patient reported increasing fatigue.", + "The patient reported subfebrile body temperatures.", + "The patient reported scalp tenderness.", + "Severe headaches of the temporal area were denied.", + "Myalgia was denied.", + "Morning stiffness was denied.", + "All symptoms started on the left side.", + "The symptoms affected both sides over time.", + "Examinations by a dentist, an orthodontist and an otolaryngologist remained without any findings.", + "The patient was alert.", + "The patient was orientated.", + "The patient had appropriate affect on clinical examination.", + "The neurological examination remained unremarkable.", + "There were no dolorous nerve exit points.", + "The swinging flashlight test was negative.", + "The tongue appeared normal.", + "The tongue showed no diversion, swelling or necrosis.", + "Palpation of the temporal arteries was normal.", + "Chest radiography was without pathologies.", + "The patient reported no history of vasoconstrictive medication.", + "There was no history of radiotherapy involving any site of the body.", + "C-reactive protein (CRP) was 71 mg/l.", + "The reference range for CRP is 0 to 5 mg/l.", + "Erythrocyte sedimentation rate was 75 mm/h.", + "The reference range for erythrocyte sedimentation rate is < 30 mm/h.", + "The best corrected visual acuity was 20/400 in the left eye.", + "The best corrected visual acuity was 20/25 in the right eye.", + "Funduscopic examination of the left eye revealed optic disc edema.", + "Funduscopic examination of the left eye revealed cotton wool spots along the upper temporal vascular arch.", + "The macula and the retinal blood vessels appeared normal on fundoscopy.", + "Optical coherence tomography (OCT) of the left macula was normal.", + "OCT of the optic disc confirmed disc edema in accordance with the clinical appearance.", + "Retinal nerve fibre layer thickness was increased in the superior, temporal and inferior segments.", + "The optic disc showed diffuse leakage on fluorescein angiography.", + "Anterior ischemic optical neuropathy (AION) of the left eye was diagnosed.", + "The patient was referred to the Department of Rheumatology at the University Hospital Bonn for further evaluation.", + "The patient underwent ultrasound examination of all arteries typically involved in GCA according to OMERACT protocol.", + "A GE Logiq S8 XDclear ultrasound machine with software version R3 manufactured in 2018 was used.", + "For sonographic examination of the axillary, vertebral and carotid arteries, a linear ultrasound probe with a range from 6 to 15 MHz was used.", + "For all other small arteries including the central retinal artery, an ultrasound probe with a range from 8 to 18 MHz was applied.", + "Vascular ultrasound demonstrated a homogeneous, concentric thickening of the intima-media complex, known as halo sign, in several arteries of the head and neck area.", + "Vasculitic affection with increased intima-media thickness (IMT) values above published cut-off values was observed in the common superficial temporal arteries on both sides.", + "Vasculitic affection with increased IMT values above published cut-off values was observed in both frontal and parietal branches.", + "Vasculitic affection with increased IMT values above published cut-off values was observed in the right facial artery.", + "Vasculitic affection with increased IMT values above published cut-off values was observed in the right axillary artery.", + "A halo sign was also visible in both vertebral arteries.", + "Due to tongue claudication and lingual pain, the deep lingual artery was also examined by ultrasound.", + "The deep lingual artery displayed a typical vasculitic halo-sign.", + "Vasculitic IMT swelling led to markedly reduced blood flow in the deep lingual artery.", + "Peak IMT of the lingual artery was 1.38 mm.", + "There was no occlusion of the lingual artery.", + "Transocular ultrasound of the central retinal artery was performed on both sides.", + "The retinal artery displayed a systolic flow velocity of 8.2 cm/s on the left eye.", + "The retinal artery displayed a systolic flow velocity of 7.5 cm/s on the right eye.", + "The ocular ultrasound findings were in agreement with both the patient’s visual symptoms and the ophthalmological findings.", + "Diagnosis of GCA was made based on the patient's symptoms, clinical examination, laboratory results and ultrasound findings.", + "Therapy was promptly initiated.", + "Due to the characteristic sonographic findings, no biopsy of the superficial temporal artery or any other artery was performed.", + "The patient received an initial daily dose of 500 mg methylprednisolone intravenous for five days.", + "The patient received a daily dose of 60 mg prednisolone per os, tapered over 26 weeks according to the GIACTA treatment protocol.", + "Tocilizumab treatment was initiated with a weekly dose of 162 mg subcutaneously.", + "Jaw claudication and tongue pain resolved within days.", + "The patient was dismissed five days later in stable clinical condition.", + "Three months after dismissal, the patient was on 9 mg prednisolone per day.", + "Three months after dismissal, the patient was on 162 mg tocilizumab subcutaneously per week.", + "Three months after dismissal, the patient was free of symptoms.", + "CRP was normal.", + "On ultrasound examination, a relevant decrease of IMT values could be observed in all affected arteries.", + "IMT of the deep lingual artery had decreased from 1.38 to 0.77 mm.", + "Systolic flow velocities of both central retinal arteries had increased from 8.2 to 21.6 cm/s on the left eye.", + "Systolic flow velocities of both central retinal arteries had increased from 7.5 to 19.1 cm/s on the right eye.", + "At ophthalmological and sonographic follow-up examination 6 months after dismissal, best corrected visual acuity increased from 20/400 to 20/40 in the left eye.", + "The right eye was still without pathological finding.", + "Funduscopic examination of the left eye showed a decrease of optic disc edema.", + "Funduscopic examination of the left eye showed a pale optic disc.", + "Funduscopic examination of the left eye showed narrow vessels.", + "OCT of the left macula revealed atrophy of inner retinal layers.", + "OCT of the optic disc confirmed absence of disc edema.", + "OCT of the optic disc showed a decrease of retinal nerve fibre layer thickness.", + "The patient was on 12.5 mg prednisolone per day.", + "The patient was on 162 mg tocilizumab subcutaneously per week.", + "The patient was free of symptoms.", + "The dose of prednisolone was increased for a short time by an external rheumatologist.", + "The increase in prednisolone was due to recurring headaches.", + "The increase in prednisolone was due to CRP-elevation between the follow-up examinations.", + "On ultrasound examination, a further decrease in IMT values could be observed.", + "Flow velocity of both central retinal arteries showed stable values with 19.1 cm/s on the left eye.", + "Flow velocity of both central retinal arteries showed stable values with 17.2 cm/s on the right eye.", + "IMT of the deep lingual artery had decreased from 0.77 to 0.34 mm.", + "Tapering of prednisolone and therapy with tocilizumab was continued following the GIACTA protocol." + ], + "summary": "We report the case of a 78-year-old woman with typical symptoms of GCA, such as scalp tenderness, jaw claudication and loss of visual field, as well as severe tongue pain. Broad vasculitic affection of the extracranial arteries, vasculitis of the central retinal artery and the deep lingual artery could be visualized by ultrasound. Further did we observe a relevant decrease of intima-media thickness (IMT) values of all arteries assessed by ultrasound during follow-up. Especially the left common superficial temporal artery showed a relevant decrease of IMT from 0.49 mm at time of diagnosis to 0.23 mm on 6-months follow-up. This is the first GCA case described in literature, in which vasculitis of the central retinal artery and the lingual artery could be visualized at diagnosis and during follow-up using high-resolution ultrasound.", + "summary_subclaims": [ + "The patient was a 78-year-old woman.", + "The patient had typical symptoms of GCA.", + "The patient had scalp tenderness.", + "The patient had jaw claudication.", + "The patient had loss of visual field.", + "The patient had severe tongue pain.", + "Broad vasculitic affection of the extracranial arteries could be visualized by ultrasound.", + "Vasculitis of the central retinal artery could be visualized by ultrasound.", + "Vasculitis of the deep lingual artery could be visualized by ultrasound.", + "There was a relevant decrease of intima-media thickness (IMT) values of all arteries assessed by ultrasound during follow-up.", + "The left common superficial temporal artery showed a relevant decrease of IMT from 0.49 mm at time of diagnosis to 0.23 mm on 6-months follow-up.", + "This is the first GCA case described in literature, in which vasculitis of the central retinal artery and the lingual artery could be visualized at diagnosis and during follow-up using high-resolution ultrasound." + ] + }, + { + "id": "multiclinsum_test_1114_en.txt", + "fulltext": "The patient, a 43-year-old female was admitted to hospital due to a right upper lobe space occupying lesion. Nine months after lung surgery, she was treated again for painless gross hematuria.\nDuring physical examination, the patient was found to have space occupying lesions in the right lung, and was first admitted to hospital for right lung lesion resection. After 9 mo, there was no obvious inducement for painless hematuria for 5 d, thus she was admitted to hospital again.\nHer past history was unremarkable. No other operations were performed during this period.\nHer family history was unremarkable.\nNine months after lung surgery, the patient was admitted to hospital again due to sudden, painless hematuria. A mass of 2.0 cm × 1.0 cm × 1.0 cm could be touched under the right chest wall, with fair activity, tough quality and a clear boundary.\nThe results of a hemogram, ESR, and other tumor markers (alpha fetoprotein, carcinoembryonic antigen, CA-125, CA-199) were all within the normal range, tuberculin skin test (5 TU PPD) was negative.\nComputed tomography (CT) image showed an irregular dense soft tissue lesion in the posterior upper lobe of the right lung, approximately 3.8 cm × 3.3 cm × 4.0 cm in size, and calcification in the periphery of the tumor .\nThe CT density of both kidneys was uneven, with patchy slightly high-density shadows in the upper and lower pole of the right kidney and the middle parenchyma of the left kidney, and an unclear boundary. Enhanced CT showed mild to moderate inhomogeneous enhancement, and the density decreased slightly in the delayed phase. The degree of enhancement was lower than that of the surrounding normal renal parenchyma. Filling defects were found in the bilateral renal veins, which showed mild enhancement. Magnetic resonance imaging (MRI) showed multiple long T1, short T2 and diffusion-weighted imaging high signals in both kidneys. Similar signal clusters were found in the left renal pelvis and upper ureter. Two dimensional ultrasonography images showed that the volume of both kidneys was increased, and several extremely low echo masses were seen in the parenchyma, with unclear and irregular boundaries, the bilateral renal veins were widened and hypoechoic filling was seen inside. Color Doppler flow imaging (CDFI) showed no obvious blood flow signals in both renal veins, and no obvious blood flow signal was found in the renal lesions. The following were seen on contrast-enhanced ultrasonography (CEUS, Figure ): Multiple solid space occupying lesions were found in both kidneys, the contrast medium filled the heart rapidly during the arterial phase, showing slightly high enhancement, and low enhancement when the contrast agent withdrew in 60 s. Metastasis of synovial sarcoma was considered based on the patient’s medical history and imaging findings.\nAccording to chest wall ultrasonography , a very low echo mass approximately 1.5 cm × 1.4 cm × 2.0 cm in size was seen in the superficial subcutaneous fascia layer, with a clear boundary, regular, aspect ratio > 1, and the echo of the surrounding fat layer was increased. On CDFI, a spot strip blood flow signal was seen inside. CEUS showed that the contrast medium filled the heart rapidly (9 s) during the arterial phase, showing overall high enhancement. After 39 s, the contrast medium quickly withdrew and showed low enhancement.\nCombined with the immunohistochemical results, postoperative pathology of pulmonary lesions indicated synovial sarcoma. Pathology of the chest wall mass and kidney mass showed that the nucleus was fusiform or ovoid in shape under the microscope with hyperchromasia, the nucleoli were not obvious, cytoplasm was sparse and unclear, and the mitotic count was rare. Pathological diagnosis was synovial sarcoma metastases .", + "fulltext_subclaims": [ + "The patient is a 43-year-old female.", + "The patient was admitted to hospital due to a right upper lobe space occupying lesion.", + "Nine months after lung surgery, she was treated again for painless gross hematuria.", + "During physical examination, the patient was found to have space occupying lesions in the right lung.", + "The patient was first admitted to hospital for right lung lesion resection.", + "After 9 mo, there was no obvious inducement for painless hematuria for 5 d.", + "The patient was admitted to hospital again.", + "Her past history was unremarkable.", + "No other operations were performed during this period.", + "Her family history was unremarkable.", + "Nine months after lung surgery, the patient was admitted to hospital again due to sudden, painless hematuria.", + "A mass of 2.0 cm × 1.0 cm × 1.0 cm could be touched under the right chest wall.", + "The mass had fair activity, tough quality, and a clear boundary.", + "The results of a hemogram, ESR, and other tumor markers were all within the normal range.", + "The tuberculin skin test (5 TU PPD) was negative.", + "Computed tomography (CT) image showed an irregular dense soft tissue lesion in the posterior upper lobe of the right lung.", + "The lesion was approximately 3.8 cm × 3.3 cm × 4.0 cm in size.", + "Calcification was seen in the periphery of the tumor.", + "The CT density of both kidneys was uneven.", + "Patchy slightly high-density shadows were seen in the upper and lower pole of the right kidney and the middle parenchyma of the left kidney.", + "The boundary was unclear.", + "Enhanced CT showed mild to moderate inhomogeneous enhancement.", + "The density decreased slightly in the delayed phase.", + "The degree of enhancement was lower than that of the surrounding normal renal parenchyma.", + "Filling defects were found in the bilateral renal veins, which showed mild enhancement.", + "Magnetic resonance imaging (MRI) showed multiple long T1, short T2, and diffusion-weighted imaging high signals in both kidneys.", + "Similar signal clusters were found in the left renal pelvis and upper ureter.", + "Two dimensional ultrasonography images showed that the volume of both kidneys was increased.", + "Several extremely low echo masses were seen in the parenchyma.", + "The boundaries were unclear and irregular.", + "The bilateral renal veins were widened and hypoechoic filling was seen inside.", + "Color Doppler flow imaging (CDFI) showed no obvious blood flow signals in both renal veins.", + "No obvious blood flow signal was found in the renal lesions.", + "Contrast-enhanced ultrasonography showed multiple solid space occupying lesions in both kidneys.", + "The contrast medium filled the heart rapidly during the arterial phase, showing slightly high enhancement.", + "Low enhancement was seen when the contrast agent withdrew in 60 s.", + "Metastasis of synovial sarcoma was considered based on the patient’s medical history and imaging findings.", + "Chest wall ultrasonography showed a very low echo mass approximately 1.5 cm × 1.4 cm × 2.0 cm in size.", + "The mass was in the superficial subcutaneous fascia layer.", + "The mass had a clear boundary, regular shape, and aspect ratio > 1.", + "The echo of the surrounding fat layer was increased.", + "Color Doppler flow imaging showed a spot strip blood flow signal inside.", + "Contrast-enhanced ultrasonography showed that the contrast medium filled the heart rapidly (9 s) during the arterial phase, showing overall high enhancement.", + "After 39 s, the contrast medium quickly withdrew and showed low enhancement.", + "Combined with the immunohistochemical results, postoperative pathology of pulmonary lesions indicated synovial sarcoma.", + "Pathology of the chest wall mass and kidney mass showed that the nucleus was fusiform or ovoid in shape under the microscope.", + "The nuclei showed hyperchromasia.", + "The nucleoli were not obvious.", + "The cytoplasm was sparse and unclear.", + "The mitotic count was rare.", + "Pathological diagnosis was synovial sarcoma metastases." + ], + "summary": "A 43-year-old female patient had a solid space occupying lesion in the right upper lobe of the lung. The results of a hemogram, erythrocyte sedimentation rate (ESR) and tumor markers were all within the normal range, tuberculin skin test (5 TU PPD) was negative (-). Chest computed tomography examination showed similar round soft tissue density in the posterior segment of the right upper lobe. Thoracoscopic-assisted wedge resection of the right upper lobe of the lung, right upper lobe resection and lymph node dissection were performed. Nine months after surgery, ultrasound examination showed multiple metastases on the chest wall and kidney.", + "summary_subclaims": [ + "The patient is a 43-year-old female.", + "The patient had a solid space occupying lesion in the right upper lobe of the lung.", + "The results of a hemogram were within the normal range.", + "The erythrocyte sedimentation rate (ESR) was within the normal range.", + "Tumor markers were within the normal range.", + "The tuberculin skin test (5 TU PPD) was negative (-).", + "Chest computed tomography showed similar round soft tissue density in the posterior segment of the right upper lobe.", + "Thoracoscopic-assisted wedge resection of the right upper lobe of the lung was performed.", + "Right upper lobe resection was performed.", + "Lymph node dissection was performed.", + "Nine months after surgery, ultrasound examination showed multiple metastases on the chest wall.", + "Nine months after surgery, ultrasound examination showed multiple metastases on the kidney." + ] + }, + { + "id": "multiclinsum_test_2038_en.txt", + "fulltext": "A 16-year-old female came with mid backache since 3 months with bilateral lower limb weakness and urinary incontinence since 5 days. The backache was localized initially, gradually progressive aggravated since the past 5 days. The backache was not associated with any constitutional symptoms but the patient reported that the pain worsened at night. She noticed weakness while getting down the stairs 5 days ago and had difficulty in maintaining her balance while walking. Her symptoms rapidly progressed over 2 days and she was unable to walk without support with increased tightness in her lower limbs and also had urinary frequency and urge incontinence. She denies any history of trauma or fall. She gave a history of having undergone an surgical instrumented intervention in the mid back region for similar complaints 1 year ago. She does not report any history of trauma. She was brought on a wheel chair to our emergency department. On physical examination, the neurological examination of the upper limb along with the higher motor functions was found to be normal. The lower limbs were found to be spastic. Power in both the lower limbs was found to be 1/5. There was impairment in the touch and the pain sensations as well. Sensory level was found to be D10. The X-ray done of 1 year back was suggestive of the corrective measures taken for ver-tebral hemangioma . The patient was then subjected to magnetic resonance imaging (MRI). The axial and the sagittal T2 images of the MRI had high intensity signals in the extra osseous portion of D9 compressing the cord, indicating of vertebral hemangioma. This lesion was causing spinal cord compression, ultimately leading to acute onset paraplegia .\nThe decision was taken by the consulting orthopedic surgeons to manage the case with surgical intervention. The patient underwent arterial embolization 12 h before surgery. Decompression with long segment instrumentation was performed (, ). On the 14th post-operative day, the patient had improved neurology with complete sensory recovery and Grade 2 power in right lower limb and Grade 1 power in the left lower limb. Histopathology report confirmed the findings correlating with that of hemangioma . At 6-month follow-up after aggressive rehabilitation, the neurology of the patient improves to Grade 3 power in the left lower limb and Grade 4 power in the right lower limb. However, the spasticity persisted but was reduced. The sphincteric control was also found to be fair at 6-month follow-up.", + "fulltext_subclaims": [ + "The patient is a 16-year-old female.", + "She had mid backache for 3 months.", + "She had bilateral lower limb weakness for 5 days.", + "She had urinary incontinence for 5 days.", + "The backache was localized initially.", + "The backache was gradually progressive.", + "The backache was aggravated in the past 5 days.", + "The backache was not associated with constitutional symptoms.", + "The backache worsened at night.", + "She noticed weakness while getting down the stairs 5 days ago.", + "She had difficulty maintaining balance while walking.", + "Her symptoms rapidly progressed over 2 days.", + "She was unable to walk without support.", + "She had increased tightness in her lower limbs.", + "She had urinary frequency.", + "She had urge incontinence.", + "She denies any history of trauma or fall.", + "She had a surgical instrumented intervention in the mid back region for similar complaints 1 year ago.", + "She does not report any history of trauma.", + "She was brought on a wheelchair to the emergency department.", + "On physical examination, the neurological examination of the upper limb and higher motor functions was normal.", + "The lower limbs were found to be spastic.", + "Power in both lower limbs was 1/5.", + "There was impairment in touch and pain sensations.", + "Sensory level was D10.", + "The X-ray done 1 year back was suggestive of corrective measures taken for vertebral hemangioma.", + "The patient underwent magnetic resonance imaging (MRI).", + "The axial and sagittal T2 images of the MRI had high intensity signals in the extra osseous portion of D9 compressing the cord, indicating vertebral hemangioma.", + "The lesion was causing spinal cord compression.", + "The spinal cord compression led to acute onset paraplegia.", + "The decision was taken by the consulting orthopedic surgeons to manage the case with surgical intervention.", + "The patient underwent arterial embolization 12 h before surgery.", + "Decompression with long segment instrumentation was performed.", + "On the 14th post-operative day, the patient had improved neurology with complete sensory recovery.", + "On the 14th post-operative day, the patient had Grade 2 power in the right lower limb.", + "On the 14th post-operative day, the patient had Grade 1 power in the left lower limb.", + "Histopathology report confirmed the findings correlating with hemangioma.", + "At 6-month follow-up after aggressive rehabilitation, the neurology of the patient improved to Grade 3 power in the left lower limb.", + "At 6-month follow-up after aggressive rehabilitation, the neurology of the patient improved to Grade 4 power in the right lower limb.", + "Spasticity persisted at 6-month follow-up.", + "Spasticity was reduced at 6-month follow-up.", + "Sphincteric control was fair at 6-month follow-up." + ], + "summary": "A 16-year-old female came with an acute history of paraparesis with bladder in-volvement. She was diagnosed of vertebral hemangioma of D9 for which she underwent surgical decompression and fixation. At present, she had paraparesis with a sensory level of D10 on exami-nation. After radiological investigations (X-ray and MRI) she had high intensity signals in the extra osseous portion of D9 with significant neural compression indicating recurrence of vertebral he-mangioma. She underwent decompression with long segment instrumentation with prior arterial embolization. Histopathology features were suggestive of hemangioma and our diagnosis of recur-rence was confirmed. At 2 weeks, the patient had improved neurology with partial sensory recovery and Grade 2 power in the right lower limb and Grade 1 power in the left lower limb. Histopathology report confirmed the diagnosis of hemangioma indicating recurrence. At 6 months follow-up after aggressive rehabilitation, the patient was spastic and improved to Grade 3 power in the left lower limb and Grade 4 power in the right lower limb. The sphincteric control was also found to be fair at 1 year follow-up.", + "summary_subclaims": [ + "A 16-year-old female came with an acute history of paraparesis with bladder involvement.", + "She was diagnosed of vertebral hemangioma of D9.", + "She underwent surgical decompression and fixation.", + "At present, she had paraparesis with a sensory level of D10 on examination.", + "After radiological investigations (X-ray and MRI), she had high intensity signals in the extra osseous portion of D9.", + "There was significant neural compression indicating recurrence of vertebral hemangioma.", + "She underwent decompression with long segment instrumentation with prior arterial embolization.", + "Histopathology features were suggestive of hemangioma.", + "Our diagnosis of recurrence was confirmed.", + "At 2 weeks, the patient had improved neurology with partial sensory recovery.", + "At 2 weeks, the patient had Grade 2 power in the right lower limb.", + "At 2 weeks, the patient had Grade 1 power in the left lower limb.", + "Histopathology report confirmed the diagnosis of hemangioma indicating recurrence.", + "At 6 months follow-up after aggressive rehabilitation, the patient was spastic.", + "At 6 months follow-up, the patient improved to Grade 3 power in the left lower limb.", + "At 6 months follow-up, the patient improved to Grade 4 power in the right lower limb.", + "The sphincteric control was also found to be fair at 1 year follow-up." + ] + }, + { + "id": "multiclinsum_test_1764_en.txt", + "fulltext": "A 44-year-old man without any past medical history or cardiac risk factors presented with retrosternal chest pain radiating to the left arm and jaw. An ECG performed by the paramedic ambulance crew showed sinus rhythm with hyper-acute T-waves in the anterior leads with borderline ST-segment elevation . On further questioning, the patient denied any chest pain symptoms prior to presentation. Suspected as having an evolving STEMI, the PPCI pathway was activated, in line with the 2017 ESC guidelines on management of ST-elevation myocardial infarction (MI), and the patient was transferred as an emergency to the cardiac catheterisation laboratory of our heart attack centre.\nOn arrival, the patient was haemodynamically stable and the chest pain had subdued to 1/10 in severity. Systemic examination was unremarkable. The patient was apyrexial, with a heart rate of 90 b.p.m., with a blood pressure of 110/72 mmHg and venous pressure was not elevated. Cardiovascular examination was normal with an undisplaced apex beat, normal heart sounds, no murmurs or pericardial rub, and normal breath sounds on auscultation.\nSubsequently, there was recurrence of severe chest pain and profound anterior ST-segment elevation . Emergency coronary angiography showed unobstructed coronary arteries . Emergency coronary angiogram showed all three coronary arteries were patent with Thrombolysis in Myocardial infarction-3 flow and there was no evidence of dissection or thrombus. The ST-elevation and pain resolved spontaneously over the next 15 min . On-table echocardiography showed no evidence of pericardial effusion or any ventricular regional wall motion abnormality. Troponin-T level rose from <3 ng/L on arrival to 549 ng/L at 12 h. Blood results were as follows: haemoglobin 139 g/L (130–170 g/L), white cell count 12.9 × 109/L (4–11 × 109/L) (differential count of 73% neutrophils, 17% lymphocytes, 7% monocytes, 2% eosinophils, and 1% basophils), platelet count 302 × 109/L (150–400 × 109/L), C-reactive protein 83 mg/L (0–5 mg/L), prothrombin time 13.5 s (9–12 s), activated partial thromboplastin time 40.4 s (23–31 s), lactate 1.4 mmol/L (0.6–2.5 mmol/L), urea 3.2 mmol/L (2.5–7.8 mmol/L), creatinine 55 µmol/L (59–104 µmol/L), eGFR >90 mL/min sodium 138 mmol/L (133–146 mmol/L), potassium 4.4 mmol/L (3.5–5.3 mmol/L), bilirubin 5 µmol/L (0–21 µmol/L), alanine transaminase 17 U/L (7–40 U/L), alkaline phosphatase 132 U/L (30–130 U/L), and albumin 42 g/L (35–50 g/L).\nThe patient was transferred to the cardiac ward and managed as a possible acute coronary syndrome or coronary artery spasm and initiated on dual anti-platelet therapy with aspirin 75 mg o.d., ticagrelor 90 mg b.i.d., diltiazem 90 mg b.i.d. and atorvastatin 20 mg o.d. Transthoracic echocardiography was normal, with normal left ventricle size and function, and no evidence of regional wall motion abnormality. He was discharged after 48 hours of monitoring, after he remained stable and symptom free.\nGiven that there was no evidence of coronary artery disease on angiography to explain the reason for the acute coronary syndrome, a cardiac magnetic resonance imaging (MRI) scan was requested, to look for evidence of MI, fibrosis, or inflammation such as myocarditis. An outpatient cardiac MRI showed a structurally normal heart but detected an incidental large mediastinal mass , measuring 90 mm × 31 mm × 74 mm that was lobulated, containing multiple cysts. The mass abutted, but did not invade, the great vessels in the anterior mediastinum. Inflammation and oedema of the parietal pericardium was observed anterior to the right ventricle confluent with some of the mass. There was no myocardial late gadolinium enhancement. The patient was reviewed in clinic where dual antiplatelet therapy was stopped and a chest computed tomography (CT) scan was arranged.\nThe chest CT scan was requested to better characterize the lesion. This showed a poorly defined anterior mediastinal mass with cystic areas with large area of contact with the great vessels and infiltrating between the ascending aorta and main pulmonary artery . Adjacent abnormal lymph nodes were also present. Tissue biopsy confirmed Hodgkin’s lymphoma and the patient was initiated on chemotherapy (Adriamycin, Bleomycin, Vinblastine and Dacarbazine, or ABVD regime). The patient was seen following five cycles of chemotherapy, 7 months following the index event and was responding well to the chemotherapy with no further symptoms of chest pain.", + "fulltext_subclaims": [ + "A 44-year-old man without any past medical history or cardiac risk factors presented with retrosternal chest pain radiating to the left arm and jaw.", + "An ECG performed by the paramedic ambulance crew showed sinus rhythm with hyper-acute T-waves in the anterior leads with borderline ST-segment elevation.", + "The patient denied any chest pain symptoms prior to presentation.", + "The PPCI pathway was activated, in line with the 2017 ESC guidelines on management of ST-elevation myocardial infarction (MI).", + "The patient was transferred as an emergency to the cardiac catheterisation laboratory of our heart attack centre.", + "On arrival, the chest pain had subdued to 1/10 in severity.", + "Systemic examination was unremarkable.", + "The patient was apyrexial, with a heart rate of 90 b.p.m., blood pressure of 110/72 mmHg, and venous pressure was not elevated.", + "Cardiovascular examination was normal with an undisplaced apex beat, normal heart sounds, no murmurs or pericardial rub, and normal breath sounds on auscultation.", + "Subsequently, there was recurrence of severe chest pain and profound anterior ST-segment elevation.", + "Emergency coronary angiography showed unobstructed coronary arteries.", + "Emergency coronary angiogram showed all three coronary arteries were patent with Thrombolysis in Myocardial infarction-3 flow.", + "There was no evidence of dissection or thrombus.", + "The ST-elevation and pain resolved spontaneously over the next 15 min.", + "On-table echocardiography showed no evidence of pericardial effusion or any ventricular regional wall motion abnormality.", + "Troponin-T level rose from <3 ng/L on arrival to 549 ng/L at 12 h.", + "The patient was managed as a possible acute coronary syndrome or coronary artery spasm.", + "The patient was initiated on dual anti-platelet therapy with aspirin 75 mg o.d., ticagrelor 90 mg b.i.d., diltiazem 90 mg b.i.d., and atorvastatin 20 mg o.d.", + "Transthoracic echocardiography was normal, with normal left ventricle size and function, and no evidence of regional wall motion abnormality.", + "The patient was discharged after 48 hours of monitoring, after he remained stable and symptom free.", + "A cardiac magnetic resonance imaging (MRI) scan was requested.", + "An outpatient cardiac MRI showed a structurally normal heart.", + "An incidental large mediastinal mass was detected, measuring 90 mm × 31 mm × 74 mm.", + "The mass abutted, but did not invade, the great vessels in the anterior mediastinum.", + "Inflammation and oedema of the parietal pericardium was observed anterior to the right ventricle confluent with some of the mass.", + "There was no myocardial late gadolinium enhancement.", + "A chest computed tomography (CT) scan was requested to better characterize the lesion.", + "The chest CT scan showed a poorly defined anterior mediastinal mass with cystic areas with large area of contact with the great vessels and infiltrating between the ascending aorta and main pulmonary artery.", + "Adjacent abnormal lymph nodes were also present.", + "Tissue biopsy confirmed Hodgkin’s lymphoma.", + "The patient was initiated on chemotherapy (Adriamycin, Bleomycin, Vinblastine and Dacarbazine, or ABVD regime).", + "The patient was seen following five cycles of chemotherapy, 7 months following the index event.", + "The patient was responding well to the chemotherapy with no further symptoms of chest pain." + ], + "summary": "A 44-year-old man was admitted with retrosternal chest pain radiating to the left arm and jaw, and electrocardiography showed extensive anterior ST-segment elevation. Emergency coronary angiography showed all three coronary arteries were patent with Thrombolysis in Myocardial Infarction-3 flow and no evidence of dissection or thrombus. The ST-elevation and pain resolved spontaneously. Troponin-T level rose from <3 ng/L on arrival to 549 ng/L at 12 h. Subsequent cardiac magnetic resonance imaging (MRI) showed a structurally normal heart (without late gadolinium enhancement) but detected an incidental large, lobulated (90 × 31 × 71 mm) mediastinal mass containing multiple cysts in the anterior mediastinum with inflammation and oedema of the parietal pericardium. Tissue biopsy confirmed Hodgkin's lymphoma and the patient was initiated on chemotherapy.", + "summary_subclaims": [ + "The patient was a 44-year-old man.", + "He was admitted with retrosternal chest pain radiating to the left arm and jaw.", + "Electrocardiography showed extensive anterior ST-segment elevation.", + "Emergency coronary angiography showed all three coronary arteries were patent with Thrombolysis in Myocardial Infarction-3 flow.", + "There was no evidence of dissection or thrombus.", + "The ST-elevation and pain resolved spontaneously.", + "Troponin-T level rose from <3 ng/L on arrival to 549 ng/L at 12 h.", + "Subsequent cardiac MRI showed a structurally normal heart without late gadolinium enhancement.", + "The MRI detected an incidental large, lobulated (90 × 31 × 71 mm) mediastinal mass containing multiple cysts in the anterior mediastinum.", + "The mass was associated with inflammation and oedema of the parietal pericardium.", + "Tissue biopsy confirmed Hodgkin's lymphoma.", + "The patient was initiated on chemotherapy." + ] + }, + { + "id": "multiclinsum_test_426_en.txt", + "fulltext": "A 64-year-old male presented as an intoxicated pedestrian who was involved in a hit-and-run incident. Initial trauma workup demonstrated that the patient had sustained a type II odontoid fracture . He subsequently underwent AOSF for this fracture, without any intraoperative complications. He tolerated the procedure well and postoperative imaging demonstrated near anatomic correction of the fracture with satisfactory placement of the lag screw [ and ]. Postoperatively, the patient was to attend physical therapy. Unfortunately, the patient was subsequently lost to follow up and he presented 7 months later for a routine outpatient CT of the cervical spine, which demonstrated upward migration of the screw into the intracranial cavity abutting the medulla , with CT angiography of the neck also demonstrating the screw lying between the two vertebral arteries . The patient had also obtained a magnetic resonance imaging of the cervical spine which demonstrated the odontoid screw lying within close proximity to the ventral cervicomedullary junction, marginating the left vertebral artery [ and ]. Although he did not exhibit any neurological symptoms at this time, given the migration of the screw, there was nonunion of the patient’s fracture with increased risk of poor recovery and neurological deterioration. He was subsequently taken for an anterior removal of the odontoid screw with posterior open treatment and reduction, C1-4 posterolateral arthrodesis and instrumented fusion, and Brooks sublaminar wire placement of C1-2 posterior instrumentation . He tolerated the procedure well and remained intact neurologically postoperatively.", + "fulltext_subclaims": [ + "The patient was a 64-year-old male.", + "The patient was an intoxicated pedestrian involved in a hit-and-run incident.", + "The patient sustained a type II odontoid fracture.", + "The patient underwent AOSF for the fracture.", + "There were no intraoperative complications.", + "The patient tolerated the procedure well.", + "Postoperative imaging demonstrated near anatomic correction of the fracture.", + "Postoperative imaging demonstrated satisfactory placement of the lag screw.", + "The patient was to attend physical therapy.", + "The patient was lost to follow up.", + "The patient presented 7 months later for a routine outpatient CT of the cervical spine.", + "The CT demonstrated upward migration of the screw into the intracranial cavity.", + "The CT demonstrated the screw abutting the medulla.", + "CT angiography of the neck demonstrated the screw lying between the two vertebral arteries.", + "The patient had obtained a magnetic resonance imaging of the cervical spine.", + "The MRI demonstrated the odontoid screw lying within close proximity to the ventral cervicomedullary junction.", + "The MRI demonstrated the screw marginating the left vertebral artery.", + "The patient did not exhibit any neurological symptoms at this time.", + "There was nonunion of the patient’s fracture.", + "There was an increased risk of poor recovery.", + "There was an increased risk of neurological deterioration.", + "The patient was taken for an anterior removal of the odontoid screw.", + "The patient underwent posterior open treatment and reduction.", + "The patient underwent C1-4 posterolateral arthrodesis and instrumented fusion.", + "The patient underwent Brooks sublaminar wire placement of C1-2 posterior instrumentation.", + "The patient tolerated the procedure well.", + "The patient remained intact neurologically postoperatively." + ], + "summary": "A 64-year-old neurologically intact patient with a type II odontoid fracture secondary to trauma underwent anterior odontoid screw fixation without any intraoperative complications. He tolerated the procedure well, and postoperative imaging demonstrated near anatomic correction of the fracture with satisfactory placement of the lag screw. Unfortunately, the patient was subsequently lost to follow up and he presented 7 months later for a routine outpatient computed tomography (CT) of the cervical spine, which demonstrated upward migration of the screw into the intracranial cavity abutting the medulla, with CT angiography of the neck also confirming the screw lying between the two vertebral arteries. Magnetic resonance imaging of the cervical spine also demonstrated the odontoid screw lying within close proximity to the ventral cervicomedullary junction, marginating the left vertebral artery. Subsequently, the patient was managed with removal of the odontoid screw and posterior cervical arthrodesis and instrumented fusion.", + "summary_subclaims": [ + "The patient is a 64-year-old man.", + "The patient had a type II odontoid fracture.", + "The fracture was secondary to trauma.", + "The patient underwent anterior odontoid screw fixation.", + "There were no intraoperative complications.", + "Postoperative imaging demonstrated near anatomic correction of the fracture.", + "Postoperative imaging showed satisfactory placement of the lag screw.", + "The patient was lost to follow up.", + "The patient presented 7 months later for a routine outpatient computed tomography of the cervical spine.", + "Computed tomography demonstrated upward migration of the screw into the intracranial cavity.", + "The screw abutted the medulla.", + "Computed tomography angiography of the neck confirmed the screw lying between the two vertebral arteries.", + "Magnetic resonance imaging of the cervical spine demonstrated the odontoid screw lying within close proximity to the ventral cervicomedullary junction.", + "The screw marginated the left vertebral artery.", + "The patient was managed with removal of the odontoid screw.", + "The patient underwent posterior cervical arthrodesis and instrumented fusion." + ] + }, + { + "id": "multiclinsum_test_1002_en.txt", + "fulltext": "In July 2006, a 41-year-old female presented with a swelling in the right preauricular region, which had persisted for the past two years, and was having difficulty opening her mouth for the past four months. The swelling was insidious in onset and progressive. In the first six months, the patient indicated the swelling was painless, only later becoming painful as the size increased.\nLocal examination found a diffuse 5 × 4 cm firm to cystic mass with restricted mobility in the right preauricular region. Examination of the oral cavity, ear, cranial nerves, and other systems was unremarkable. MRI analysis indicated a large mass in the right infratemporal fossa with significant infiltration into the adjoining muscles. This mass was hypo-isointense on T1 and heterogeneously hyperintense on T2 weighted images . The mass had significant enhancement in post-contrast MRI . Hematological and biochemistry analyses were normal. Fine needle aspiration cytology (FNAC) revealed a monotonous population of small, round lymphoid cells with regular nuclei, compact chromatin, inconspicuous nucleoli, and scant basophilic cytoplasm. These findings were consistent with NHL. Diagnostic biopsy of the tissue confirmed small lymphocytic non-Hodgkin's lymphoma. The patient was investigated further to determine the staging of the NHL, but no lymph node or other organ was found to be involved. The patient was scheduled for chemo-radiation treatment and given nine cycles of the CHOP regime (cyclophosphamide, doxarubicine, vicristine, and prednisolone) and a total of 55G radiation in 25 fractions over five weeks. The patient remained asymptomatic for seven months.\nIn Nov 2007, the patient again presented with similar symptoms. A computed axial tomography (CT) scan revealed a hypodense mass of 37 Hounsefield unit (HU) density and measuring 4.25 cm × 4.0 cm in the right temporal and infratemporal region. Post-contrast, this mass showed heterogeneous enhancement (66 HU density) and normal contents (muscles) were not identifiable from the mass. The tumor was excised and histopathology again confirmed the diagnosis of NHL. The patient was given six cycles of ifosfamide, metoxantron, and etoposide, with the last cycle on June 3rd, 2008. The patient was on regular follow up, and in Aug 2008 presented with increasing trismus. On examination, the infratemporal fossa was normal but there was a hard, irregular ulcer in the right retromolar area . A punch biopsy of the ulcer found it to be a well-differentiated squamous cell carcinoma. The patient was advised to undergo surgery for this carcinoma, but she did not come in for further follow up.", + "fulltext_subclaims": [ + "In July 2006, a 41-year-old female presented with a swelling in the right preauricular region.", + "The swelling had persisted for the past two years.", + "The patient was having difficulty opening her mouth for the past four months.", + "The swelling was insidious in onset and progressive.", + "In the first six months, the patient indicated the swelling was painless.", + "Later, the swelling became painful as the size increased.", + "Local examination found a diffuse 5 × 4 cm firm to cystic mass with restricted mobility in the right preauricular region.", + "MRI analysis indicated a large mass in the right infratemporal fossa with significant infiltration into the adjoining muscles.", + "The mass was hypo-isointense on T1 and heterogeneously hyperintense on T2 weighted images.", + "The mass had significant enhancement in post-contrast MRI.", + "Fine needle aspiration cytology (FNAC) revealed a monotonous population of small, round lymphoid cells with regular nuclei, compact chromatin, inconspicuous nucleoli, and scant basophilic cytoplasm.", + "These findings were consistent with NHL.", + "Diagnostic biopsy of the tissue confirmed small lymphocytic non-Hodgkin's lymphoma.", + "The patient was scheduled for chemo-radiation treatment.", + "The patient was given nine cycles of the CHOP regime (cyclophosphamide, doxarubicine, vicristine, and prednisolone).", + "The patient received a total of 55G radiation in 25 fractions over five weeks.", + "The patient remained asymptomatic for seven months.", + "In Nov 2007, the patient again presented with similar symptoms.", + "A computed axial tomography (CT) scan revealed a hypodense mass of 37 Hounsefield unit (HU) density and measuring 4.25 cm × 4.0 cm in the right temporal and infratemporal region.", + "Post-contrast, this mass showed heterogeneous enhancement (66 HU density).", + "The tumor was excised.", + "Histopathology again confirmed the diagnosis of NHL.", + "The patient was given six cycles of ifosfamide, metoxantron, and etoposide.", + "The last cycle was on June 3rd, 2008.", + "In Aug 2008, the patient presented with increasing trismus.", + "On examination, the infratemporal fossa was normal.", + "There was a hard, irregular ulcer in the right retromolar area.", + "A punch biopsy of the ulcer found it to be a well-differentiated squamous cell carcinoma.", + "The patient was advised to undergo surgery for this carcinoma.", + "The patient did not come in for further follow up." + ], + "summary": "We present a case of a 41-year-old female that presented with swelling in the right preauricular region that had persisted for the past two years. The patient was diagnosed as having a small lymphocytic NHL. She initially underwent chemo-radiation but reported relapse. The tumor was excised and again the patient underwent chemotherapy. The patient remained symptomatic and developed a second primary squamous cell carcinoma in the right retromolar trigone.", + "summary_subclaims": [ + "The patient is a 41-year-old female.", + "The patient had swelling in the right preauricular region.", + "The swelling had persisted for the past two years.", + "The patient was diagnosed as having a small lymphocytic NHL.", + "The patient initially underwent chemo-radiation.", + "The patient reported relapse.", + "The tumor was excised.", + "The patient underwent chemotherapy.", + "The patient remained symptomatic.", + "The patient developed a second primary squamous cell carcinoma.", + "The second primary squamous cell carcinoma was in the right retromolar trigone." + ] + }, + { + "id": "multiclinsum_test_2744_en.txt", + "fulltext": "A 70-year-old man was admitted to our hospital for obstructive jaundice. He had undergone distal gastrectomy with Roux-en-Y reconstruction for gastric cancer concomitant with cholecystectomy for cholecystolithiasis approximately 10 years prior at a different hospital. The pathological staging of his gastric cancer was SS, N0, M0, stage IB. Gastric cancer recurrence was not detected during postoperative surveillance by computed tomography (CT) imaging or blood examination . In November 2016, further examination for repeated episodes of epigastralgia revealed the presence of obstructive jaundice. The patient’s serum total and direct bilirubin levels were 4.2 and 2.4 mg/dL, respectively. Moreover, hepatobiliary dysfunction was detected and the patient’s serum alkaline phosphatase, aspartate aminotransferase, alanine aminotransferase, and gamma-glutamyl transferase levels were 474 IU/L, 264 IU/L, 496 IU/L, and 676 IU/L, respectively. C-reactive protein was elevated at 11.2 mg/dL. CT examination revealed CBD dilatation with a high-density area . On a series of surveillance CT images, a spotted high-density area in the CBD was confirmed in a retrospective analysis following the onset of cholangitis . Multi-plane reconstructed (MPR) CT revealed a CBD stone along the length of the CBD that contained a needle-shaped calcification density at its center . The patient was diagnosed as acute cholangitis concomitant with CBD stone. Gastroenterologists at our center and from a nearby hospital deemed that it would be difficult and tentative to perform endoscopic therapy to remove the stone through the Roux-en-Y reconstructed intestine. Therefore, the surgical procedure was adopted as quick and reliable treatment option and was performed using the upper median laparotomy approach. A severe adhesion, resulting from prior surgeries (namely distal gastrectomy and cholecystectomy), was found between the liver and the hepatoduodenal ligament. Even though the CBD was carefully exposed to adhesiolysis, a choledocoduodenal fistula was not detected. Lithotomy with choledochotomy was performed to remove one fragile bilirubin stone that had formed around a 3-cm, needle-shaped fish bone . The choledochotomy was closed by interrupted sutures using a polyglactin 910 suture. CBD drainage was not performed. The needle-shaped foreign body was diagnosed as a fish bone by histological hematoxylin and eosin staining and infrared absorption spectrophotometry . The patient’s postoperative course was uneventful and free of adverse events. The patient was discharged on postoperative day 21. No recurrence of a CBD foreign body was identified over the 4 years since the surgery.", + "fulltext_subclaims": [ + "A 70-year-old man was admitted to our hospital for obstructive jaundice.", + "He had undergone distal gastrectomy with Roux-en-Y reconstruction for gastric cancer concomitant with cholecystectomy for cholecystolithiasis approximately 10 years prior at a different hospital.", + "The pathological staging of his gastric cancer was SS, N0, M0, stage IB.", + "Gastric cancer recurrence was not detected during postoperative surveillance by computed tomography (CT) imaging or blood examination.", + "In November 2016, further examination for repeated episodes of epigastralgia revealed the presence of obstructive jaundice.", + "The patient’s serum total and direct bilirubin levels were 4.2 and 2.4 mg/dL, respectively.", + "Hepatobiliary dysfunction was detected.", + "The patient’s serum alkaline phosphatase, aspartate aminotransferase, alanine aminotransferase, and gamma-glutamyl transferase levels were 474 IU/L, 264 IU/L, 496 IU/L, and 676 IU/L, respectively.", + "C-reactive protein was elevated at 11.2 mg/dL.", + "CT examination revealed CBD dilatation with a high-density area.", + "On a series of surveillance CT images, a spotted high-density area in the CBD was confirmed in a retrospective analysis following the onset of cholangitis.", + "Multi-plane reconstructed (MPR) CT revealed a CBD stone along the length of the CBD that contained a needle-shaped calcification density at its center.", + "The patient was diagnosed as acute cholangitis concomitant with CBD stone.", + "Gastroenterologists at our center and from a nearby hospital deemed that it would be difficult and tentative to perform endoscopic therapy to remove the stone through the Roux-en-Y reconstructed intestine.", + "The surgical procedure was adopted as quick and reliable treatment option and was performed using the upper median laparotomy approach.", + "A severe adhesion, resulting from prior surgeries (namely distal gastrectomy and cholecystectomy), was found between the liver and the hepatoduodenal ligament.", + "Even though the CBD was carefully exposed to adhesiolysis, a choledocoduodenal fistula was not detected.", + "Lithotomy with choledochotomy was performed to remove one fragile bilirubin stone that had formed around a 3-cm, needle-shaped fish bone.", + "The choledochotomy was closed by interrupted sutures using a polyglactin 910 suture.", + "CBD drainage was not performed.", + "The needle-shaped foreign body was diagnosed as a fish bone by histological hematoxylin and eosin staining and infrared absorption spectrophotometry.", + "The patient’s postoperative course was uneventful and free of adverse events.", + "The patient was discharged on postoperative day 21.", + "No recurrence of a CBD foreign body was identified over the 4 years since the surgery." + ], + "summary": "A 70-year-old man was admitted to our hospital due to repeated episodes of epigastralgia. He had undergone distal gastrectomy with Roux-en-Y reconstruction for gastric cancer approximately 10 years prior. Blood tests revealed obstructive jaundice, hepatobiliary dysfunction, and inflammation. Multi-plane reconstructed computed tomography (CT) revealed a CBD stone with a needle-shaped calcification density at the center, oriented along the length of the CBD. Surgery was performed using an upper median laparotomy approach. Lithotomy with choledochotomy was performed to remove one fragile bilirubin stone that had formed around a 3-cm, needle-shaped fish bone. A choledochoduodenal fistula was not detected intraoperatively. A review of the imaging of a prior examination revealed that the formation of the CBD stone around the fish bone was observable on a follow-up CT performed approximately 2 years prior. However, no clinical symptoms associated with the migration of the fish bone to the CBD were reported and the fish bone was not detected at that time.", + "summary_subclaims": [ + "A 70-year-old man was admitted to our hospital due to repeated episodes of epigastralgia.", + "He had undergone distal gastrectomy with Roux-en-Y reconstruction for gastric cancer approximately 10 years prior.", + "Blood tests revealed obstructive jaundice.", + "Blood tests revealed hepatobiliary dysfunction.", + "Blood tests revealed inflammation.", + "Multi-plane reconstructed computed tomography (CT) revealed a CBD stone with a needle-shaped calcification density at the center.", + "The calcification density was oriented along the length of the CBD.", + "Surgery was performed using an upper median laparotomy approach.", + "Lithotomy with choledochotomy was performed to remove one fragile bilirubin stone.", + "The bilirubin stone had formed around a 3-cm, needle-shaped fish bone.", + "A choledochoduodenal fistula was not detected intraoperatively.", + "A review of the imaging of a prior examination revealed that the formation of the CBD stone around the fish bone was observable on a follow-up CT performed approximately 2 years prior.", + "No clinical symptoms associated with the migration of the fish bone to the CBD were reported.", + "The fish bone was not detected at that time." + ] + }, + { + "id": "multiclinsum_test_2403_en.txt", + "fulltext": "A 61-year-old White man, non-smoker, with a diagnosis of long-standing arterial hypertension of difficult control, severe heart failure with a left ventricular ejection fraction of 30% receiving pharmacological treatment with carvedilol, ivabradine and losartan, and history of stage IIIB chronic renal failure without dialysis therapy. A year before the current admission, he consulted for urinary symptoms that rapidly evolved to systemic compromise with fever, diaphoresis, low back pain, hypotension, dyspnea, and increased acute phase reactants. He required hospitalization in the intensive care unit for multidisciplinary treatment with a diagnosis of sepsis of urinary origin. Alterations in calcium behavior were detected, which were associated to the underlying renal disease and to a severe hyperparathyroidism secondary to a functional adenoma in the lower left parathyroid treated with surgery, achieving control of symptoms and levels of calcium and phosphorus. Chest x-ray showed 2 lesions of tumor aspect with internal lytic areas in the fourth right and eighth left costal arches. The first lesion measured 25 × 21 mm with involvement of fourth right costal arch and the second measured 77 × 54 mm in eighth left costal arch showing growth toward the left pleural cavity . Both lesions were suggestive of a tumor of chondral origin, enchondroma, and as it was not possible to rule out malignancy with the images, he was admitted in our institution for excisional biopsy. The physical examination revealed a thin patient with chronic disease and a deformity in the neck with anterior flexion pronounced by severe dorsal kyphoscoliosis and secondary asymmetry of the right ribcage, which was retracted with decreased intercostal spaces. He referred increased dyspnea with the activities of daily life, with NYHA (New York Heart Association) functional class III. Blood pressure 120/70 mm Hg, heart rate 100 beats per minute, breathing frequency 16 breaths per minute, no cyanosis, with jugular engorgement at 90°, no neck masses, tachycardic rhythmic heart with no murmurs or gallop, decreased breath sounds at both lung bases, abdomen without ascites or masses, and extremities with edema grade II. No identifiable lesions in the chest wall other than deformity by kyphoscoliosis were found.\nBlood work was unremarkable, except for mild anemia of normal volumes (see ), spirometry showed a moderate restrictive ventilatory pattern and no significant post-bronchodilator changes and diffusing capacity of carbon monoxide, in normal limits (diffusing capacity of the lungs for carbon monoxide [DLCO]: 109%). The chronic kidney disease was stable. Thoracic computed tomography (CT) scan showed a heterogeneous rounded lytic lesion with sclerotic edges and growth toward the pulmonary cavity, of expansive type, causing displacement of pulmonary parenchyma, and measuring approximately 77 × 54 mm and depending on the eighth left costal arch . Given the size and characteristics of the mass, it was very difficult to determine if the lung was surrounding the lesion or if the mass was in fact infiltrating the parenchyma. In addition, in the fourth right costal arch, an image of similar characteristics, but smaller in size, is found, measuring 25 × 21 mm. In addition, a severe dorsal kyphoscoliosis was identified. No further studies were implemented; the decision was made to perform a surgical resection of the mass with the possibility of having to do a lobectomy.\nThe patient was hospitalized in the intensive care unit for pre-surgical conditioning where a left ventricular ejection fraction of 30% was evidenced and a cycle of intravenous levosimendan was initiated. He received red blood cell transfusion and underwent resection of the left costal mass by thoracoscopy. During the surgical procedure, only 1 hard lesion was found that involved the eighth rib and soft tissues of the seventh to ninth left ribs, without infiltration into the lung tissue or pleural cavity. Therefore, only partial resection of these 3 ribs was necessary, without pulmonary lobectomy, the right side was not intervened. In the immediate postsurgical period, the patient presented a difficult evolution, with hemodynamic instability, required vasoactive support with norepinephrine, prolonged mechanical ventilation, and a need for a tracheostomy to assist a long-standing recovery process. Subsequently, it was possible to remove the vasoactive drugs, the invasive ventilatory support, and the tracheostomy with complete physical and respiratory rehabilitation.", + "fulltext_subclaims": [ + "The patient is a 61-year-old White man.", + "The patient is a non-smoker.", + "The patient has a diagnosis of long-standing arterial hypertension of difficult control.", + "The patient has severe heart failure with a left ventricular ejection fraction of 30%.", + "The patient is receiving pharmacological treatment with carvedilol, ivabradine, and losartan.", + "The patient has a history of stage IIIB chronic renal failure without dialysis therapy.", + "A year before the current admission, he consulted for urinary symptoms.", + "The urinary symptoms rapidly evolved to systemic compromise with fever, diaphoresis, low back pain, hypotension, dyspnea, and increased acute phase reactants.", + "He required hospitalization in the intensive care unit for multidisciplinary treatment.", + "The diagnosis was sepsis of urinary origin.", + "Alterations in calcium behavior were detected.", + "The alterations in calcium behavior were associated to the underlying renal disease.", + "The alterations in calcium behavior were associated to a severe hyperparathyroidism secondary to a functional adenoma in the lower left parathyroid.", + "The functional adenoma in the lower left parathyroid was treated with surgery.", + "Surgery achieved control of symptoms and levels of calcium and phosphorus.", + "Chest x-ray showed 2 lesions of tumor aspect with internal lytic areas in the fourth right and eighth left costal arches.", + "The first lesion measured 25 × 21 mm with involvement of fourth right costal arch.", + "The second lesion measured 77 × 54 mm in eighth left costal arch showing growth toward the left pleural cavity.", + "Both lesions were suggestive of a tumor of chondral origin, enchondroma.", + "It was not possible to rule out malignancy with the images.", + "He was admitted in our institution for excisional biopsy.", + "The physical examination revealed a thin patient with chronic disease.", + "The physical examination revealed a deformity in the neck with anterior flexion pronounced by severe dorsal kyphoscoliosis.", + "The physical examination revealed secondary asymmetry of the right ribcage, which was retracted with decreased intercostal spaces.", + "He referred increased dyspnea with the activities of daily life, with NYHA functional class III.", + "Blood pressure was 120/70 mm Hg.", + "Heart rate was 100 beats per minute.", + "Breathing frequency was 16 breaths per minute.", + "There was no cyanosis.", + "There was jugular engorgement at 90°.", + "There were no neck masses.", + "The heart was tachycardic and rhythmic with no murmurs or gallop.", + "Breath sounds were decreased at both lung bases.", + "The abdomen had no ascites or masses.", + "The extremities had edema grade II.", + "No identifiable lesions in the chest wall other than deformity by kyphoscoliosis were found.", + "Blood work was unremarkable, except for mild anemia of normal volumes.", + "Spirometry showed a moderate restrictive ventilatory pattern.", + "There were no significant post-bronchodilator changes.", + "Diffusing capacity of carbon monoxide was in normal limits (DLCO: 109%).", + "The chronic kidney disease was stable.", + "Thoracic computed tomography (CT) scan showed a heterogeneous rounded lytic lesion with sclerotic edges and growth toward the pulmonary cavity.", + "The lesion was of expansive type, causing displacement of pulmonary parenchyma.", + "The lesion measured approximately 77 × 54 mm and depended on the eighth left costal arch.", + "It was very difficult to determine if the lung was surrounding the lesion or if the mass was infiltrating the parenchyma.", + "In the fourth right costal arch, an image of similar characteristics, but smaller in size, was found, measuring 25 × 21 mm.", + "A severe dorsal kyphoscoliosis was identified.", + "No further studies were implemented.", + "The decision was made to perform a surgical resection of the mass with the possibility of having to do a lobectomy.", + "The patient was hospitalized in the intensive care unit for pre-surgical conditioning.", + "A left ventricular ejection fraction of 30% was evidenced.", + "A cycle of intravenous levosimendan was initiated.", + "He received red blood cell transfusion.", + "He underwent resection of the left costal mass by thoracoscopy.", + "During the surgical procedure, only 1 hard lesion was found that involved the eighth rib and soft tissues of the seventh to ninth left ribs.", + "The lesion did not infiltrate into the lung tissue or pleural cavity.", + "Only partial resection of these 3 ribs was necessary.", + "The right side was not intervened.", + "In the immediate postsurgical period, the patient presented a difficult evolution.", + "The patient had hemodynamic instability.", + "The patient required vasoactive support with norepinephrine.", + "The patient had prolonged mechanical ventilation.", + "The patient needed a tracheostomy to assist a long-standing recovery process.", + "Subsequently, it was possible to remove the vasoactive drugs.", + "The invasive ventilatory support was removed.", + "The tracheostomy was removed.", + "The patient had complete physical and respiratory rehabilitation." + ], + "summary": "We report the case of a patient with a history of multiple diseases and 2 tumor-like lesions with internal lytic areas detected in the fourth right costal arch and in the eighth left costal arc; we describe his clinical manifestations, radiological and laboratory findings as well as the pathological results and outcome.", + "summary_subclaims": [ + "The patient had a history of multiple diseases.", + "Two tumor-like lesions with internal lytic areas were detected.", + "One lesion was located in the fourth right costal arch.", + "One lesion was located in the eighth left costal arc.", + "Clinical manifestations were described.", + "Radiological findings were described.", + "Laboratory findings were described.", + "Pathological results were described.", + "The outcome was described." + ] + }, + { + "id": "multiclinsum_test_3284_en.txt", + "fulltext": "A 14-year-old male patient was admitted for extraction of the third molars in January 2022. During the clinical evaluation, a non-painful restriction of oral opening was observed, which made it difficult to eat solid food and to carry out adequate oral hygiene. There was also an interincisal separation of 15 mm at the maximum oral opening, anterior overbite, mandibular deviation to the right side and restriction of lateral movements. During the examination, the patient stated that the restriction had been gradually and slowly developing for approximately 3 years, with a sensation of “scraping” under the zygomatic arch when opening the mouth.\n\nIn the initial panoramic radiograph, the image of both coronoid processes was observed to be superior to their respective zygomatic arches, so a computed tomography (CT) was requested. In the volumetric reconstructions of the patient with the mouth closed in maximum intercuspidation, an increase in volume of the AC was observed, of homogeneous density, with an attenuation coefficient ranging from 633.7 UH to 208.9 UH. In axial images, towards the inner face of the zygomatic bone on both sides, a hyperdense image suggestive of exostosis was observed, of greater size in the zygomatic arch of the right side, closely related to the enlargement of the coronoid processes. In the closed mouth, the position of the AC was posterior to the exostosis, while on the left side it was in an anterior position in relation to the ipsilateral exostosis.\n\nA bilateral coronoidectomy was performed via intraoral approach through the anterior border of the mandibular branch and subperiosteal dissection to expose the coronoid processes. At this time, mouth opening movements were performed and the premature contact of the processes with the posterior face of the zygomatic bone was observed. The disinsertion of the temporal muscle and an ostectomy at the base of the processes were performed and the processes were removed. The specimens were sent for histopathological analysis, which revealed normal morphology of trabecular and cortical bone tissue with abundant adipose tissue.\n\nIn the immediate post-surgical control, performed by means of clinical evaluation, the increase in millimetres of the oral opening was observed, 30 mm and, through the orthopantomography, the sharp and precise cut of both coronoidectomies was verified.\n\nThe patient came for evaluation at 12 months with a 30 mm oral opening, which was not painful. He had orthodontic appliances as a surgical preparation for the correction of dento-skeletal deformity class II. A CT was indicated, and a recurrence of bilateral hyperplasia of coronoid apophysis was observed. The pre-surgical images were compared.\n\nIn the comparative study of the exostoses observed in axial image, towards the inner face of both zygomatic arches, a significant reduction of the same was observed, with greater evidence on the right side.\n\nConservative management was decided upon, with physiotherapy and clinical monitoring by measuring the mouth opening with a vernier caliper every three months for the duration of the orthodontic treatment.\n", + "fulltext_subclaims": [ + "The patient was a 14-year-old male.", + "The patient was admitted for extraction of the third molars in January 2022.", + "A non-painful restriction of oral opening was observed.", + "The restriction made it difficult to eat solid food.", + "The restriction made it difficult to carry out adequate oral hygiene.", + "The interincisal separation at maximum oral opening was 15 mm.", + "There was anterior overbite.", + "There was mandibular deviation to the right side.", + "There was restriction of lateral movements.", + "The patient stated the restriction had been gradually and slowly developing for approximately 3 years.", + "The patient described a sensation of 'scraping' under the zygomatic arch when opening the mouth.", + "In the initial panoramic radiograph, both coronoid processes were observed to be superior to their respective zygomatic arches.", + "A computed tomography (CT) was requested.", + "In volumetric reconstructions with the mouth closed in maximum intercuspidation, an increase in volume of the AC was observed.", + "The AC had homogeneous density.", + "The attenuation coefficient ranged from 633.7 UH to 208.9 UH.", + "In axial images, a hyperdense image suggestive of exostosis was observed on the inner face of the zygomatic bone on both sides.", + "The exostosis was greater in size on the right zygomatic arch.", + "The exostosis was closely related to the enlargement of the coronoid processes.", + "In the closed mouth, the position of the AC was posterior to the exostosis on the right side.", + "In the closed mouth, the position of the AC was anterior to the exostosis on the left side.", + "A bilateral coronoidectomy was performed via intraoral approach.", + "The approach was through the anterior border of the mandibular branch.", + "Subperiosteal dissection was performed to expose the coronoid processes.", + "Mouth opening movements were performed during the procedure.", + "Premature contact of the processes with the posterior face of the zygomatic bone was observed.", + "The disinsertion of the temporal muscle was performed.", + "An ostectomy at the base of the processes was performed.", + "The processes were removed.", + "The specimens were sent for histopathological analysis.", + "The histopathological analysis revealed normal morphology of trabecular and cortical bone tissue.", + "The histopathological analysis revealed abundant adipose tissue.", + "In the immediate post-surgical control, an increase in millimetres of the oral opening was observed.", + "The oral opening was 30 mm in the immediate post-surgical control.", + "The sharp and precise cut of both coronoidectomies was verified through orthopantomography.", + "The patient came for evaluation at 12 months.", + "At 12 months, the oral opening was 30 mm.", + "The oral opening at 12 months was not painful.", + "The patient had orthodontic appliances as surgical preparation for the correction of dento-skeletal deformity class II.", + "A CT was indicated.", + "A recurrence of bilateral hyperplasia of coronoid apophysis was observed.", + "Pre-surgical images were compared.", + "In the comparative study of the exostoses, a significant reduction was observed.", + "The reduction was greater on the right side.", + "Conservative management was decided upon.", + "Physiotherapy was included in the management.", + "Clinical monitoring by measuring the mouth opening with a vernier caliper every three months was planned.", + "The monitoring was to continue for the duration of the orthodontic treatment." + ], + "summary": "A 14-year-old male patient with no contributing medical history is presented who was referred for progressive oral opening limitation since childhood. After clinical and imaging evaluation, he was treated with bilateral total coronoidectomy and a one-year postoperative follow-up was performed, in which a relapse was observed.\n", + "summary_subclaims": [ + "The patient is a 14-year-old male.", + "The patient has no contributing medical history.", + "The patient was referred for progressive oral opening limitation since childhood.", + "After clinical and imaging evaluation, he was treated with bilateral total coronoidectomy.", + "A one-year postoperative follow-up was performed.", + "A relapse was observed." + ] + }, + { + "id": "multiclinsum_test_1092_en.txt", + "fulltext": "A 74-year-old man was intubated in emergency for acute ischemic stroke, and then referred to Anesthesiology and Intensive Care Unit of our hospital. The patient’s medical history included cardiac disease and COPD. PDT was then performed, and patient returned to spontaneous breathing 15 days later. Despite systemic administration of broad-spectrum antibiotics (Vancomycin, Cefepime, and Azithromycin), he developed APF following necrotizing pneumonia that complicated with pneumothorax, empyema and subcutaneous emphysema . A 32 French tube was placed at the 5th intercostal space anterior axillar line with drainage of 1.500 l of brownish, putrid, and foul-swelling fluid. A negative suction (− 20 mmHg) was applied to chest drainage and daily chest X-ray showed the expansion of upper and middle lobe, but a loculated pneumothorax within lower lobe was seen on chest CT scan performed 15 days . A second 28 French chest tube was then placed using ultrasound as guide at the 8th intercostal space posterior axillar line with drainage of 500 mL of purulent material. The microbiological cultures of pleural fluid showed the presence of Pseudomonas aeruginosa; thus, ofloxacin (400 mg every 12 h) and ceftazidime (2 g every 8 h) were intravenously administered, in addition to clindamycin to provide empiric coverage against anaerobes and gram-positive cocci bacteria. The pleural space was also irrigated with 0.1% povidone-iodine solution (Betadine; 40 mL/h) until the eradication of pleural infection was obtained. However, the formation of dense adhesions trapped the lower lobe, and prevented its expansion ; yet, the persistence of large bubbles in the drainage suspected the presence of APF. Methylene blue (1 ampoule diluted in 1-l saline solution) was injected via chest drainage into the pleural cavity, and was bronchoscopically identified within RB9 segment . The resolution of air leaks obtained by occluding the RB9 segment with an inflated-balloon catheter confirmed it to be the culprit segment. Thus, a Zephyr 5.5 EBV (Zephyr, PulmonX Corporation-Redwood City, CA, USA) was placed within RB9 segment with temporary resolution of air leaks that recurred 4 days later due to valve dislocation. The valve was removed and the RB9 segment closed by intrabronchial injection of 10 mL of FG (Tisseel: Baxter Healthcare Corp, Deerfield, IL, USA) . The procedure was repeated twice at 1-week interval, but in both cases the fibrin clot dislocated.\nFinally, fiber bronchoscopy, introduced through the chest drainage, explored the pleural cavity and showed a small APF that was marked by methylene blue following intrabronchial injection of the blue solution within RB9 segment . The APF was filled by 20 mL of FG using a dedicated double-lumen catheter introduced through the working channel of fiber bronchoscopy . Furthermore, the RB9 segment was occluded by intrabronchial injection of 10 mL of FG. The chest drainage was then clamped, and a bronchial blocker was left with the balloon inflated within intermedius bronchus to prevent the intrapleural, and intrabronchial dislocation of fibrin clot, respectively. Two days later, the bronchial blocker was deflated, and the chest drainage opened. No recurrence of air-leaks occurred; drainage of non-purulent fluid was < 100 mL/24 h; chest CT scan showed no evidence of worsening pneumothorax, and of progressive subcutaneous emphysema; thus, chest tube was removed . Patient was then transferred to a rehabilitation center. He died 11 months later for cardiac failure. The entire procedure was summarized in Additional file 1: Video S1.", + "fulltext_subclaims": [ + "A 74-year-old man was intubated in emergency for acute ischemic stroke.", + "The patient’s medical history included cardiac disease.", + "The patient’s medical history included COPD.", + "PDT was then performed.", + "The patient returned to spontaneous breathing 15 days later.", + "He developed APF following necrotizing pneumonia.", + "A 32 French tube was placed at the 5th intercostal space anterior axillar line.", + "A negative suction (− 20 mmHg) was applied to chest drainage.", + "Daily chest X-ray showed the expansion of upper and middle lobe.", + "A second 28 French chest tube was then placed using ultrasound as guide at the 8th intercostal space posterior axillar line.", + "The microbiological cultures of pleural fluid showed the presence of Pseudomonas aeruginosa.", + "Ofloxacin (400 mg every 12 h) and ceftazidime (2 g every 8 h) were intravenously administered.", + "The pleural space was irrigated with 0.1% povidone-iodine solution.", + "The formation of dense adhesions trapped the lower lobe.", + "Methylene blue was injected via chest drainage into the pleural cavity.", + "Methylene blue was bronchoscopically identified within RB9 segment.", + "A Zephyr 5.5 EBV was placed within RB9 segment.", + "The valve was removed and the RB9 segment closed by intrabronchial injection of 10 mL of FG.", + "The procedure was repeated twice at 1-week interval.", + "Fiber bronchoscopy explored the pleural cavity.", + "The APF was filled by 20 mL of FG using a dedicated double-lumen catheter.", + "The RB9 segment was occluded by intrabronchial injection of 10 mL of FG.", + "The chest drainage was then clamped.", + "A bronchial blocker was left with the balloon inflated within intermedius bronchus.", + "No recurrence of air-leaks occurred.", + "Chest CT scan showed no evidence of worsening pneumothorax.", + "Chest tube was removed.", + "Patient was then transferred to a rehabilitation center.", + "He died 11 months later for cardiac failure." + ], + "summary": "A 74-year-old man was intubated in emergency for acute ischemic stroke. Percutaneous dilatational tracheostomy was then performed, and 15 days later patient returned to spontaneous breathing. However, he developed alveolar pleural fistula following necrotizing pneumonia with persistent air leaks. The intrabronchial and intrapleural injection of fibrin glue using fiber bronchoscopy sealed off the alveolar pleura fistula after that other endoscopic treatments as bronchial valve and intrabronchial fibrin glue application had failed.", + "summary_subclaims": [ + "The patient was a 74-year-old man.", + "The patient was intubated in emergency for acute ischemic stroke.", + "Percutaneous dilatational tracheostomy was performed.", + "The patient returned to spontaneous breathing 15 days later.", + "The patient developed alveolar pleural fistula following necrotizing pneumonia.", + "The patient had persistent air leaks.", + "Intrabronchial and intrapleural injection of fibrin glue using fiber bronchoscopy sealed off the alveolar pleura fistula.", + "Other endoscopic treatments as bronchial valve and intrabronchial fibrin glue application had failed." + ] + }, + { + "id": "multiclinsum_test_2706_en.txt", + "fulltext": "A 58-year-old Caucasian man was referred to the eye clinic in view of multiple raised yellowish lesions in both fundi. He had originally visited his optician for occasional flashes and floaters. He had recently been diagnosed with diet controlled type 2 diabetes mellitus and was on a low dose of amlodipine (5mg/day) for well controlled hypertension. His other drug history included analgesics (paracetamol, dihydrocodeine) and omeprazole. He admitted to heavy alcohol consumption in the past and had chronic liver disease with ascites.\nHis examination revealed that he had hepatomegaly with a palpable liver edge three fingerbreadths below the right costal margin, but no splenomegaly. An ultrasound of the liver showed generally increased echogenicity suggestive of liver cirrhosis. A computed tomography (CT) scan confirmed the presence of liver cirrhosis and showed evidence of esophageal varices, in keeping with decompensated chronic liver disease.\nThere was no evidence of a localized lesion in the liver, ruling out the possibility of both hepatocellular carcinoma and metastatic disease as causes of decompensation. His liver function tests (LFTs), including alkaline phosphatase (ALP), alanine aminotransferase (ALT) and γ-glutamyl transferase (GGT), had been elevated for several years. Interestingly, he was also found to have a marginally elevated plasma viscosity of 1.81mPa/s (normal range 1.5 to 1.72mPa/s) with no evidence of paraprotein.\nHis ocular examination was within normal limits for the anterior segment. His visual acuity was 6/6 in both eyes. Ophthalmoscopic examination of both eyes revealed a symmetrical pattern of dozens of variably sized, slightly yellowish, translucent raised lesions throughout the fundi . These lesions were confirmed as multiple neurosensory retinal detachments on optical coherence tomography (OCT) and fundus autofluorescence . The patient was followed-up in the eye clinic and was asymptomatic until his last follow-up. Visual acuity, fundus and OCT findings were unchanged. As the visual acuity was good and there was no evidence of choroidal neovascularization, conservative management was recommended.", + "fulltext_subclaims": [ + "A 58-year-old Caucasian man was referred to the eye clinic in view of multiple raised yellowish lesions in both fundi.", + "He had recently been diagnosed with diet controlled type 2 diabetes mellitus.", + "He was on a low dose of amlodipine (5mg/day) for well controlled hypertension.", + "He admitted to heavy alcohol consumption in the past.", + "He had chronic liver disease with ascites.", + "His examination revealed hepatomegaly with a palpable liver edge three fingerbreadths below the right costal margin.", + "An ultrasound of the liver showed generally increased echogenicity suggestive of liver cirrhosis.", + "A computed tomography (CT) scan confirmed the presence of liver cirrhosis.", + "The CT scan showed evidence of esophageal varices.", + "There was no evidence of a localized lesion in the liver.", + "The possibility of both hepatocellular carcinoma and metastatic disease as causes of decompensation was ruled out.", + "His liver function tests (LFTs), including alkaline phosphatase (ALP), alanine aminotransferase (ALT) and γ-glutamyl transferase (GGT), had been elevated for several years.", + "He was also found to have a marginally elevated plasma viscosity of 1.81mPa/s.", + "There was no evidence of paraprotein.", + "His ocular examination was within normal limits for the anterior segment.", + "His visual acuity was 6/6 in both eyes.", + "Ophthalmoscopic examination of both eyes revealed a symmetrical pattern of dozens of variably sized, slightly yellowish, translucent raised lesions throughout the fundi.", + "The lesions were confirmed as multiple neurosensory retinal detachments on optical coherence tomography (OCT) and fundus autofluorescence.", + "The patient was followed-up in the eye clinic and was asymptomatic until his last follow-up.", + "Visual acuity, fundus and OCT findings were unchanged.", + "As the visual acuity was good and there was no evidence of choroidal neovascularization, conservative management was recommended." + ], + "summary": "A 58-year-old Caucasian man with alcoholic liver disease, liver cirrhosis and ascites presented to the eye clinic. The ophthalmoscopic examination of both eyes revealed a symmetrical pattern of variably sized, slightly yellowish, translucent, raised lesions throughout the fundi which were confirmed to be caused by multifocal central serous retinopathy after optical coherence tomography and autofluoresence tests.", + "summary_subclaims": [ + "The patient is a 58-year-old Caucasian man.", + "The patient has alcoholic liver disease.", + "The patient has liver cirrhosis.", + "The patient has ascites.", + "The patient presented to the eye clinic.", + "The ophthalmoscopic examination of both eyes revealed a symmetrical pattern of variably sized, slightly yellowish, translucent, raised lesions throughout the fundi.", + "The lesions were confirmed to be caused by multifocal central serous retinopathy.", + "Optical coherence tomography and autofluorescence tests were performed." + ] + }, + { + "id": "multiclinsum_test_265_en.txt", + "fulltext": "A 75-year-old man with a history of stage 4 prostate carcinoma that was first diagnosed in 2008 developed an idiopathic limbal stem cell deficiency and underwent bilateral keratoepithelioplasty by a previous doctor in 2011. He was prescribed the therapeutic contact lenses postoperatively. He was referred to our clinic for further ophthalmic therapy in November 2012.\nOur initial examination found that he had bilateral end-stage primary open-angle glaucoma, prior bilateral keratoepithelioplasty, and phacoemulsification with posterior chamber intraocular lens implantation in the left eye. His decimal visual acuity with Landolt broken ring chart was 0.07 in the right eye and 0.2 in the left eye, and his intraocular pressures were 13 mmHg in the right eye and 13 mmHg in the left eye. He had been treated with 0.3% topical gatifloxacin and 0.1% topical fluorometholone twice a day, topical travoprost and timolol maleate once a day, and 1% topical dorzolamide hydrochloride three times a day for glaucoma. He was also prescribed therapeutic contact lenses for both eyes to protect the corneal epithelium. Systemically, he had stage 4 prostate carcinoma and had had a cerebral infarction. He had been treated with oral anti-androgen drug and 0.1mg/day of dexamethasone. His general condition was very poor. He was examined monthly, and his ocular condition had stabilized by September 2015. His decimal visual acuity with Landolt broken ring chart was 0.2 in the right and left eyes, and his intraocular pressures were 6 mmHg in the right and left eyes in September 2015.\nHe visited our clinic in October 2015 with blurred vision in his left eye of two weeks duration. Our slit-lamp examination showed a greyish-white epithelial opacity in the central cornea of his left eye . His decimal visual acuity with Landolt broken ring chart was 0.2 in the right eye and 0.07 in the left eye, and his intraocular pressures were 14 mmHg in the right eye and 15 mmHg in the left eye. The patient was advised to stop using the therapeutic contact lens and 0.1% topical fluorometholone. Fungiflora Y staining of cultures of corneal smears and therapeutic contact lens swabs were negative for fungus but Gram-positive organisms were detected. The organisms were unicellular, spherical, and contained multiple endospores . We identified the organisms as Prototheca spp. based on the morphology. He was started on topical 0.3% tobramycin four times a day, but he could not continue because of irritation. So, 0.5% AMPH-B ointment was prescribed three times a day along with 0.2% topical FLCZ six times a day, and corneal surface debridement was performed four times. The keratitis improved and 4 months later a culture of the ocular surface was negative for Prototheca spp..\nWe planned to continue the AMPH-B and FLCZ treatments but had to stop the eye treatments because of a worsening of his general condition. Two months later, a greyish-white epithelial opacity in the cornea of his left eye was detected again . We considered either continuing with the medical treatments or performing therapeutic penetrating keratoplasty (PKP) even though there was a risk of disseminating Prototheca into the intraocular space. We presented the risks of both treatment plans, and the patient declined undergoing therapeutic PKP. So, he was retreated with 0.5% AMPH-B ointment three times a day and 0.2% topical FLCZ six times a day without debridement, and the lesion did not recur. From November 2016 to April 2018, the grayish-white lesion continued to recur during periods of radiation for the recurrence of the prostate carcinoma and invasion of the urinary bladder. We continued the AMPH-B and FLCZ treatments, and the lesions were improved whenever his general condition recovered. The recurrent lesions were intermittent and remained only in the epithelial layer and did not spread into deeper layers. In April 2018, 300 mg/day of oral VRCZ was added to the treatment regimen because new grayish-white epithelial infiltrations were noted. Two months later he stopped the oral medication because he was diagnosed by his oncologist to be at the terminal stage, and he was switched topical 1% VRCZ six times a day. The infiltration was slowly resolved but he died in September 2018.", + "fulltext_subclaims": [ + "The patient is a 75-year-old man.", + "He has a history of stage 4 prostate carcinoma.", + "The prostate carcinoma was first diagnosed in 2008.", + "He developed an idiopathic limbal stem cell deficiency.", + "He underwent bilateral keratoepithelioplasty by a previous doctor in 2011.", + "He was prescribed therapeutic contact lenses postoperatively.", + "He was referred to our clinic for further ophthalmic therapy in November 2012.", + "Our initial examination found bilateral end-stage primary open-angle glaucoma.", + "He had prior bilateral keratoepithelioplasty.", + "He had phacoemulsification with posterior chamber intraocular lens implantation in the left eye.", + "His decimal visual acuity with Landolt broken ring chart was 0.07 in the right eye.", + "His decimal visual acuity with Landolt broken ring chart was 0.2 in the left eye.", + "His intraocular pressures were 13 mmHg in the right eye.", + "His intraocular pressures were 13 mmHg in the left eye.", + "He had been treated with 0.3% topical gatifloxacin and 0.1% topical fluorometholone twice a day.", + "He had been treated with topical travoprost and timolol maleate once a day.", + "He had been treated with 1% topical dorzolamide hydrochloride three times a day for glaucoma.", + "He was prescribed therapeutic contact lenses for both eyes to protect the corneal epithelium.", + "Systemically, he had stage 4 prostate carcinoma.", + "He had had a cerebral infarction.", + "He had been treated with oral anti-androgen drug.", + "He had been treated with 0.1mg/day of dexamethasone.", + "His general condition was very poor.", + "He was examined monthly.", + "His ocular condition had stabilized by September 2015.", + "His decimal visual acuity with Landolt broken ring chart was 0.2 in the right and left eyes in September 2015.", + "His intraocular pressures were 6 mmHg in the right and left eyes in September 2015.", + "He visited our clinic in October 2015 with blurred vision in his left eye of two weeks duration.", + "Our slit-lamp examination showed a greyish-white epithelial opacity in the central cornea of his left eye.", + "His decimal visual acuity with Landolt broken ring chart was 0.2 in the right eye.", + "His decimal visual acuity with Landolt broken ring chart was 0.07 in the left eye.", + "His intraocular pressures were 14 mmHg in the right eye.", + "His intraocular pressures were 15 mmHg in the left eye.", + "The patient was advised to stop using the therapeutic contact lens.", + "The patient was advised to stop using 0.1% topical fluorometholone.", + "Fungiflora Y staining of cultures of corneal smears and therapeutic contact lens swabs were negative for fungus.", + "Gram-positive organisms were detected.", + "The organisms were unicellular, spherical, and contained multiple endospores.", + "We identified the organisms as Prototheca spp. based on the morphology.", + "He was started on topical 0.3% tobramycin four times a day.", + "He could not continue because of irritation.", + "0.5% AMPH-B ointment was prescribed three times a day.", + "0.2% topical FLCZ six times a day was prescribed.", + "Corneal surface debridement was performed four times.", + "The keratitis improved.", + "Four months later a culture of the ocular surface was negative for Prototheca spp.", + "We planned to continue the AMPH-B and FLCZ treatments.", + "We had to stop the eye treatments because of a worsening of his general condition.", + "Two months later, a greyish-white epithelial opacity in the cornea of his left eye was detected again.", + "We considered either continuing with the medical treatments or performing therapeutic penetrating keratoplasty (PKP).", + "We presented the risks of both treatment plans.", + "The patient declined undergoing therapeutic PKP.", + "He was retreated with 0.5% AMPH-B ointment three times a day.", + "He was retreated with 0.2% topical FLCZ six times a day.", + "The lesion did not recur.", + "From November 2016 to April 2018, the grayish-white lesion continued to recur during periods of radiation for the recurrence of the prostate carcinoma.", + "The grayish-white lesion continued to recur during periods of invasion of the urinary bladder.", + "We continued the AMPH-B and FLCZ treatments.", + "The lesions were improved whenever his general condition recovered.", + "The recurrent lesions were intermittent.", + "The recurrent lesions remained only in the epithelial layer.", + "The recurrent lesions did not spread into deeper layers.", + "In April 2018, 300 mg/day of oral VRCZ was added to the treatment regimen.", + "New grayish-white epithelial infiltrations were noted.", + "Two months later he stopped the oral medication.", + "He was diagnosed by his oncologist to be at the terminal stage.", + "He was switched to topical 1% VRCZ six times a day.", + "The infiltration was slowly resolved.", + "He died in September 2018." + ], + "summary": "A 75-year-old man with a history of stage 4 prostate carcinoma and bilateral limbal stem cell deficiency had undergone keratoepithelioplasty on his left eye for the deficiency. Postoperatively, a greyish-white epithelial opacity was noted on the central cornea of his left eye, and he had been treated with topical fluorometholone and oral dexamethasone together with a therapeutic contact lens. Corneal smears and contact lens swabs were positive for Prototheca spp. He required a continuous treatment with amphotericin B (AMPH-B) ointment, topical fluconazole (FLCZ), and voriconazole (VRCZ). This treatment protocol was effective, but recurrences developed when his general condition worsened.", + "summary_subclaims": [ + "The patient is a 75-year-old man.", + "The patient has a history of stage 4 prostate carcinoma.", + "The patient has bilateral limbal stem cell deficiency.", + "The patient had undergone keratoepithelioplasty on his left eye.", + "Postoperatively, a greyish-white epithelial opacity was noted on the central cornea of his left eye.", + "He had been treated with topical fluorometholone and oral dexamethasone.", + "He had been treated with a therapeutic contact lens.", + "Corneal smears were positive for Prototheca spp.", + "Contact lens swabs were positive for Prototheca spp.", + "He required continuous treatment with amphotericin B ointment.", + "He required continuous treatment with topical fluconazole.", + "He required continuous treatment with voriconazole.", + "This treatment protocol was effective.", + "Recurrences developed when his general condition worsened." + ] + }, + { + "id": "multiclinsum_test_1556_en.txt", + "fulltext": "A 59-year-old woman born in Southern Italy was admitted to our ward in March 2020 after experiencing malaise, nausea, vomiting and fever lasting about a week. Chest x-ray showed bilateral basal interstitial pneumonia and SARS-CoV-2 RT-PCR in a oropharyngeal/nasal swab resulted positive. Since arterial pO2 was 57 mmHg, she was started on high-flow supplemental oxygen support. The patient reported chronic treatment with low dose prednisone for adult Still’s disease since 2010 and atenolol for hypertension.\nTreatment with hydroxychloroquine, lopinavir/ritonavir, and dexamethasone was started together with enoxaparin prophylaxis. On the 5th day of hospitalization due to severe hypoxia and worsening of respiratory performance, she underwent non-invasive mechanical ventilation with continuous positive airway pressure (CPAP), which was continued for a total of 11 days. On day 7th she was treated with two doses of tocilizumab 8 mg/kg 12 h apart. Dexamethasone treatment was given at the dose of 20 mg/day for 5 days, followed by 10 mg/day for other 6 days. During the hospitalization, she presented an episode of atrial fibrillation, which was successfully reverted by amiodarone, and hyperglycemia, for which she started insulin-based treatment, later switched to oral hypoglycemic agents. Overall her clinical condition gradually improved, and she completed oxygen weaning on day 27th of hospitalization.\nOn day 25th her eosinophil absolute count (EAC) increased up to 5540 cell/µL and the patient reported abdominal pain and itching. Stool examination revealed the presence of rhabditiform larvae of S. stercoralis, while IFAT serology tested positive at a titre of 1:640. A 4-day oral treatment with ivermectin (200 mcg/kg) was administered, with a rapid decrease of eosinophil cell count and symptom improvement. She was discharged and a follow-up visit 1 month later was scheduled to check EAC, serology for S. stercoralis and stool examination.\nThe patient did not develop fever or worsening clinical condition concomitant to EAC rising. She denied travelling to tropical or subtropical areas and revealed recent moving to Lombardia region from Calabria region (Southern Italy). She reported repeated episodes of diffuse itching in the last 10 years, treated with topical steroids with partial improvement.", + "fulltext_subclaims": [ + "The patient was a 59-year-old woman born in Southern Italy.", + "She was admitted in March 2020.", + "She experienced malaise, nausea, vomiting, and fever lasting about a week.", + "Chest x-ray showed bilateral basal interstitial pneumonia.", + "SARS-CoV-2 RT-PCR in an oropharyngeal/nasal swab resulted positive.", + "Arterial pO2 was 57 mmHg.", + "She was started on high-flow supplemental oxygen support.", + "She reported chronic treatment with low dose prednisone for adult Still’s disease since 2010.", + "She reported chronic treatment with atenolol for hypertension.", + "Treatment with hydroxychloroquine, lopinavir/ritonavir, and dexamethasone was started.", + "Enoxaparin prophylaxis was started.", + "On the 5th day of hospitalization, she underwent non-invasive mechanical ventilation with CPAP.", + "CPAP was continued for a total of 11 days.", + "On day 7, she was treated with two doses of tocilizumab 8 mg/kg 12 h apart.", + "Dexamethasone treatment was given at the dose of 20 mg/day for 5 days.", + "Dexamethasone treatment was followed by 10 mg/day for other 6 days.", + "She presented an episode of atrial fibrillation.", + "Atrial fibrillation was successfully reverted by amiodarone.", + "She started insulin-based treatment for hyperglycemia.", + "Insulin-based treatment was later switched to oral hypoglycemic agents.", + "She completed oxygen weaning on day 27 of hospitalization.", + "On day 25, her eosinophil absolute count increased up to 5540 cell/µL.", + "The patient reported abdominal pain and itching.", + "Stool examination revealed the presence of rhabditiform larvae of S. stercoralis.", + "IFAT serology tested positive at a titre of 1:640.", + "A 4-day oral treatment with ivermectin (200 mcg/kg) was administered.", + "There was a rapid decrease of eosinophil cell count.", + "Symptoms improved.", + "She was discharged.", + "A follow-up visit 1 month later was scheduled.", + "The patient did not develop fever or worsening clinical condition concomitant to EAC rising.", + "She denied travelling to tropical or subtropical areas.", + "She revealed recent moving to Lombardia region from Calabria region.", + "She reported repeated episodes of diffuse itching in the last 10 years.", + "She reported treatment with topical steroids with partial improvement." + ], + "summary": "We report a case of a 59-year-old Italian patient treated with high dose intravenous dexamethasone and two intravenous doses of Tocilizumab for interstitial bilateral pneumonia associated with SARS-CoV-2 infection who developed itching, abdominal pain, and an increased eosinophil count. Stool examination confirmed the presence of S. stercoralis larvae. The patient was treated with a 4-day course of Ivermectin with full recovery.", + "summary_subclaims": [ + "The patient was a 59-year-old Italian.", + "The patient was treated with high dose intravenous dexamethasone.", + "The patient received two intravenous doses of Tocilizumab.", + "The patient had interstitial bilateral pneumonia.", + "The pneumonia was associated with SARS-CoV-2 infection.", + "The patient developed itching.", + "The patient developed abdominal pain.", + "The patient had an increased eosinophil count.", + "Stool examination confirmed the presence of S. stercoralis larvae.", + "The patient was treated with a 4-day course of Ivermectin.", + "The patient had full recovery." + ] + }, + { + "id": "multiclinsum_test_356_en.txt", + "fulltext": "This 43-year-old woman was previously in good health. She visited the emergent department of Taichung Veterans general hospital in Taichung city of Taiwan due to fever with chills and left flank pain on 14th September 2015. Post-void dribbling with difficulty in emptying bladder and decreased urinary amount for each micturition were also noted during the two-day period prior to admission. Physical examination revealed left flank knocking pain and abdominal dullness over suprapublic area. Laboratory data revealed 22000/cumm of white blood cell, 10 mg/dL of C-reactive protein, 2.1 meq/L of serum potassium, 2.35 mg/dL of serum creatinine, and pyuria (10-20/high power field). Abdominal computed tomography (Philips diamond select brilliance CT 64-slice) showed solitary left kidney with mild hydronephrosis. The patient also complained about severe nausea and vomiting for one week. She was then admitted to the department of nephrology. All data are summarized in . Soon after administration of 1st generation of cephalosporin and Foley insertion, she became afebrile. The urinary culture yielded Proteus. The hypokalemia was deemed to be most likely vomiting-related. Pyelonephritis and hypokalemia are commonly diagnosed and treated. However, to our surprise, only the left kidney was observed , and two uteruses were found (uterus didelphys) . The urinary bladder was compressed by the two uteruses , which caused left mild hydronephrosis and compensated hypertrophy. In addition, right cervico-vaginal partial obstruction (obstructed hemivagina-communicant) was identified . After meticulous tracing of her medical history, she claimed she had seven spontaneous abortions (G9P2SA7), and she never experienced any surgical interventions except two caesarean sections. She had chronic pelvic pain, recurrent severe dysmenorrhea, spotting, and intermenstrual bleeding since her menarche. All manifestations of OHVIRA syndrome (uterus didelphys, obstructed hemivagina, and ipsilateral renal agenesis) were found in this patient. Family history was checked but she did not have any family history regarding this congenital abnormality. We treated her by antibiotics and the insertion of Foley. There was not any surgery for her because of well response for medical treatments and stable vital signs. Soon, she was discharged after one-week intravenous antibioitics and received one-week oral antiobiotics at outpatient department, too. After this episode, she was under regular follow-up and there was no more UTI within one year. This study had been approved by patient herself and she signed the informed consent.", + "fulltext_subclaims": [ + "The patient is a 43-year-old woman.", + "She visited the emergent department of Taichung Veterans general hospital.", + "She had fever with chills and left flank pain.", + "She had post-void dribbling.", + "She had difficulty in emptying the bladder.", + "She had decreased urinary amount for each micturition.", + "Physical examination revealed left flank knocking pain.", + "Physical examination revealed abdominal dullness over the suprapubic area.", + "Laboratory data revealed 22000/cumm of white blood cell.", + "Laboratory data revealed 10 mg/dL of C-reactive protein.", + "Laboratory data revealed 2.1 meq/L of serum potassium.", + "Laboratory data revealed 2.35 mg/dL of serum creatinine.", + "Laboratory data revealed pyuria (10-20/high power field).", + "Abdominal computed tomography showed a solitary left kidney.", + "Abdominal computed tomography showed mild hydronephrosis.", + "She complained about severe nausea and vomiting for one week.", + "She was admitted to the department of nephrology.", + "Soon after administration of 1st generation of cephalosporin and Foley insertion, she became afebrile.", + "The urinary culture yielded Proteus.", + "The hypokalemia was deemed to be most likely vomiting-related.", + "The patient had two uteruses (uterus didelphys).", + "The urinary bladder was compressed by the two uteruses.", + "Right cervico-vaginal partial obstruction (obstructed hemivagina-communicant) was identified.", + "She had seven spontaneous abortions.", + "She had chronic pelvic pain since menarche.", + "She had recurrent severe dysmenorrhea since menarche.", + "She had spotting since menarche.", + "She had intermenstrual bleeding since menarche.", + "All manifestations of OHVIRA syndrome were found in this patient.", + "She did not have any family history regarding this congenital abnormality.", + "She was treated by antibiotics and the insertion of Foley.", + "There was not any surgery for her.", + "She was discharged after one-week intravenous antibiotics.", + "She received one-week oral antibiotics at outpatient department.", + "After this episode, she was under regular follow-up.", + "There was no more UTI within one year.", + "This study had been approved by patient herself.", + "She signed the informed consent." + ], + "summary": "Herlyn-Werner-Wunderlich syndrome or OHVIRA syndrome is a very rare congenital anomaly with uterus didelphys, obstructed hemivagina, and ipsilateral renal agenesis. The earliest presentation of this syndrome is hematocolpos that develops during menstruation and results in dysmenorrhea and a pelvic mass shortly after menarche. Herein, we report a patient with Herlyn-Werner-Wunderlich syndrome manifested with unusual symptoms, delayed onset and without surgery. The unique point of this patient is the partial obstruction of cervico-vaginal junction.", + "summary_subclaims": [ + "Herlyn-Werner-Wunderlich syndrome is a very rare congenital anomaly.", + "Herlyn-Werner-Wunderlich syndrome is also known as OHVIRA syndrome.", + "Herlyn-Werner-Wunderlich syndrome includes uterus didelphys.", + "Herlyn-Werner-Wunderlich syndrome includes obstructed hemivagina.", + "Herlyn-Werner-Wunderlich syndrome includes ipsilateral renal agenesis.", + "The earliest presentation of this syndrome is hematocolpos.", + "Hematocolpos develops during menstruation.", + "Hematocolpos results in dysmenorrhea.", + "Hematocolpos results in a pelvic mass shortly after menarche.", + "We report a patient with Herlyn-Werner-Wunderlich syndrome.", + "The patient had unusual symptoms.", + "The patient had delayed onset.", + "The patient did not undergo surgery.", + "The unique point of this patient is the partial obstruction of cervico-vaginal junction." + ] + }, + { + "id": "multiclinsum_test_1412_en.txt", + "fulltext": "A 54-yr-old Caucasian male was referred for evaluation of a rapidly increasing neck tumor noticed for the first time four months earlier. He complained of sporadic dysphagia without weight loss. He was a heavy smoker until recently but had no previous medical history. He worked as a house painter, for seven years, in his thirties. The physical examination revealed an asymmetric multinodular goiter with a left dominant nodule with firm consistency and no palpable regional nodes. Serum TSH was 1.3 μUI/ml (normal: 0.5–4.7 μUI/ml), T4 7.3 μg/dl (normal: 5.4–11 μg/dl) and T3 126 ng/dl (normal: 52–160 ng/dl). Antimicrosomal and antithyroglobulin antibodies were negative. A thyroid ultrasound demonstrated a multinodular gland with the right and left lobes measuring 6 × 4 × 3 cm and 9 × 7 × 6 cm respectively. A computed tomography (CT) scan of the neck showed a slight tracheal deviation to the right without compression. A Tc-99 m scintigraphy disclosed irregular uptake in both lobes of the thyroid and a large cold nodule in the left lobe. FNAC from both lobes revealed a clear-cell carcinoma with an immunocytochemical profile suggestive of a secondary tumor from the kidney (refer to section pathology).\nFNAC results prompted a clinical and radiographic investigation. An abdominal CT scan revealed a tumor of the left kidney measuring in greatest diameter 10 cm. Bone scan, chest computed tomography scan, liver ultrasound and laboratory data were normal and there was no evidence of other distant metastases.\nInitial treatment included a left radical nephrectomy and a total thyroidectomy. One year later, there was evidence for cervical nodal metastases. The patient was then submitted to right radical neck dissection with internal jugular vein ligation and section of spinal accessory nerve and left modified radical neck dissection type III. At histological examination, only right nodes were metastatic.\nBoth thyroid lobes were sampled. Smears were air dried and acetone fixed and stained with May-Grünwald-Giemsa (MGG) and Papanicolaou (PAP) stains, respectively. An additional sample was fixed in formalin and processed as a cell-block using the Shandon Cytoblock® Kit (Thermo Electron Corporation, Pittsburgh, PA, USA). Cell block (CB) sections were stained with hematoxilin-eosin. Immunocytochemistry was performed on CB sections, using an avidin-biotin method with diaminobenzidine as the chromogen for the following antibodies: thyroglobulin, calcitonin, vimentin, CD10, TTF1 (Dakocytomation, Denmark A/S) and cytokeratin AE1/AE3 (Zymed Laboratories, Inc, San Francisco, CA).\nSmears consisted of a clear, large cell neoplasia with large nuclei, prominent nucleoli and finely vacuolated cytoplasm, with indistinct borders. The tumor cells were arranged in aggregates of variable size and shape, many of them centered by thin walled capillaries. This intimate relationship of neoplastic cells and vessels was better appreciated on cell-block sections. These cells were immunoreactive for pancytokeratin (AE1/AE3), vimentin and CD10 and were negative for thyroglobulin, thyroid transcription factor1 (TTF1) and calcitonin .\nThe smear pattern together with the immunocytochemical profile was consistent with the diagnosis of secondary tumor, most probably from renal origin.\nThe nephrectomy specimen showed a renal cell carcinoma, clear cell type. It was classified as Fuhrman 3 and showed extra renal local spread and no vascular invasion.\nThe thyroid gland was multinodular and all the nodules consisted of metastasis of a clear cell neoplasia. The histological pattern was similar to the renal tumor. Immunocytochemical study was performed using the same antibodies that were tested on cytological samples with identical results.\nRNA from cells left inside of the needle used for FNAC was isolated with the QuickPrep micro mRNA Purification Kit (Amersham Pharmacia Biotech, Buckinghamshire, UK), according to the manufacturer's instructions. Half of the RNA was reversed transcribed with Superscript (Invitrogen Corporation, Carlsbad, CA, USA) in 20 μl reaction volume with random primers and cDNA kept frozen. To screen for VHL mutations in thyroid aspirates, 2,5 μl of first-strand cDNA was used as a template for PCR using primers designed by us (F-5'-TCAGAGATGCAGGGACACAC-3', R-5'-TGACGATGTCCAGTCTCCTG-3').\nSomatic DNA was extracted from samples corresponding to renal carcinoma and thyroid metastases obtained during surgeries and immediately frozen with liquid nitrogen until nucleic acid extraction using TRIzol Reagent (Life Technologies, Inc., Gaithersburg, MD, USA). Genomic DNA was also obtained from peripheral venous blood and isolated by a manual method adapted from Bowtell .\nDNA samples were amplified by PCR using primers previously described . The screening of VHL mutations was performed by single-strand conformational polymorphism analysis (SSCP). To further characterize the abnormal pattern observed in the SSCP, PCR purified products were either sequenced directly using the ABI PRISM® BigDye™ Terminator Cycle Sequencing Ready Reaction Kit (Applied Biosystems, Foster City, CA, USA) and the ABI PRISM 310 Genetic Analyser or subcloned into pGEM®-T Easy Vector (Promega, Madison, USA), and subsequently sequenced using the ABI PRISM® BigDye™ Terminator Cycle Sequencing Ready Reaction Kit (Applied Biosystems, Foster City, CA, USA) and the ABI PRISM 310 Genetic Analyser. Restriction analysis, using the restriction endonuclease BstZ17 I (New England BioLabs®, Inc., Beverly, USA) was also performed.\nThe same alteration, a heterozygous 680delA (codon 156/exon 3) of the VHL gene was identified in thyroid aspirates, renal carcinoma, thyroid metastases and lymph node metastases. It causes a frame-shift and creates a premature stop predicting a truncated pVHL . Constitutional DNA (peripheral venous blood) was analyzed and did not show the mutation. No other alterations were observed in exons 1 and 2 of VHL.", + "fulltext_subclaims": [ + "The patient is a 54-yr-old Caucasian male.", + "The patient was referred for evaluation of a rapidly increasing neck tumor.", + "The tumor was first noticed four months earlier.", + "The patient complained of sporadic dysphagia.", + "The patient had no weight loss.", + "The patient was a heavy smoker until recently.", + "The patient had no previous medical history.", + "The patient worked as a house painter for seven years in his thirties.", + "The physical examination revealed an asymmetric multinodular goiter.", + "The left dominant nodule had firm consistency.", + "No palpable regional nodes were found.", + "Serum TSH was 1.3 μUI/ml.", + "T4 was 7.3 μg/dl.", + "T3 was 126 ng/dl.", + "Antimicrosomal and antithyroglobulin antibodies were negative.", + "A thyroid ultrasound showed a multinodular gland.", + "The right and left lobes measured 6 × 4 × 3 cm and 9 × 7 × 6 cm respectively.", + "A CT scan showed a slight tracheal deviation to the right.", + "Tc-99 m scintigraphy disclosed irregular uptake in both lobes.", + "A large cold nodule was found in the left lobe.", + "FNAC from both lobes revealed clear-cell carcinoma.", + "The immunocytochemical profile was suggestive of a secondary tumor from the kidney.", + "An abdominal CT scan revealed a 10 cm tumor of the left kidney.", + "Bone scan, chest CT, liver ultrasound, and laboratory data were normal.", + "There was no evidence of other distant metastases.", + "Initial treatment included left radical nephrectomy.", + "Initial treatment included total thyroidectomy.", + "One year later, there was evidence for cervical nodal metastases.", + "The patient was submitted to right radical neck dissection.", + "The patient was submitted to left modified radical neck dissection type III.", + "Histological examination showed only right nodes were metastatic.", + "Smears consisted of clear, large cell neoplasia with large nuclei.", + "The tumor cells were arranged in aggregates centered by thin walled capillaries.", + "The cells were immunoreactive for pancytokeratin (AE1/AE3).", + "The cells were immunoreactive for vimentin.", + "The cells were immunoreactive for CD10.", + "The cells were negative for thyroglobulin.", + "The cells were negative for TTF1.", + "The cells were negative for calcitonin.", + "The smear pattern and immunocytochemical profile were consistent with a secondary tumor.", + "The nephrectomy specimen showed clear cell renal cell carcinoma.", + "The tumor was classified as Fuhrman 3.", + "The tumor showed extra renal local spread.", + "The tumor showed no vascular invasion.", + "The thyroid gland was multinodular.", + "All the nodules consisted of metastasis of clear cell neoplasia.", + "The histological pattern was similar to the renal tumor.", + "Immunocytochemical study on thyroid samples showed identical results to cytological samples.", + "RNA was isolated from cells left in the needle used for FNAC.", + "RNA was isolated using the QuickPrep micro mRNA Purification Kit.", + "cDNA was obtained using Superscript.", + "VHL mutations were screened in thyroid aspirates.", + "The same alteration, a heterozygous 680delA (codon 156/exon 3) of the VHL gene, was identified in thyroid aspirates.", + "The same alteration was identified in renal carcinoma.", + "The same alteration was identified in thyroid metastases.", + "The same alteration was identified in lymph node metastases.", + "The alteration causes a frame-shift and creates a premature stop predicting a truncated pVHL.", + "Constitutional DNA (peripheral venous blood) was analyzed.", + "Constitutional DNA did not show the mutation.", + "No other alterations were observed in exons 1 and 2 of VHL." + ], + "summary": "A 54-yr-old Caucasian male complaining of a rapidly increasing neck tumor was diagnosed as having a clear-cell tumor by fine-needle aspiration cytology. A positive staining for cytokeratin as well as for vimentin and CD10 in the absence of staining for thyroglobulin, calcitonin and TTF1 suggested a renal origin confirmed by computed tomography. Using frozen RNA, obtained from cells left inside the needle used for fine needle aspiration cytology, it was possible to identify a somatic mutation (680 delA) in the VHL gene.", + "summary_subclaims": [ + "The patient is a 54-yr-old Caucasian male.", + "The patient complained of a rapidly increasing neck tumor.", + "The tumor was diagnosed as a clear-cell tumor by fine-needle aspiration cytology.", + "The tumor stained positively for cytokeratin.", + "The tumor stained positively for vimentin.", + "The tumor stained positively for CD10.", + "The tumor did not stain for thyroglobulin.", + "The tumor did not stain for calcitonin.", + "The tumor did not stain for TTF1.", + "Computed tomography confirmed a renal origin.", + "A somatic mutation (680 delA) in the VHL gene was identified using frozen RNA from cells left inside the needle used for fine needle aspiration cytology." + ] + }, + { + "id": "multiclinsum_test_2027_en.txt", + "fulltext": "In February 2018, a 26-year-old female patient presented to our hospital with progressively worsening anal pain, constipation, and hematochezia for approximately two years. She had given birth right two and a half years previously. She had no prior medical history and family history of gastrointestinal malignancies. On admission, her vital signs were stable. Digital rectal examination revealed an ulcerated 5-cm indurated lesion located at the nine o’clock position and 2 cm from the anal verge, with bleeding upon palpation. The blood tests showed elevated carcinoembryonic antigen (CEA) (10.51 ng/ml; reference range, < 3.4 ng/ml) and carbohydrate antigen 19-9 (CA19-9) (40.49 U/ml; reference range, < 22 U/ml). The diagnosis of poorly differentiated adenocarcinoma was established by flexible sigmoidoscopy with biopsies and histological examination. Computed tomography (CT) of the chest and abdomen and magnetic resonance imaging (MRI) of the pelvic confirmed the tumor stage of cT3N1M0 . Radiologic examinations did not detect metastasis to the liver, bone, lung, or breast.\nFollowing consultancy with the multidisciplinary team, the patient underwent prophylactic transverse colostomy to avoid upcoming obstruction and then received 6 cycles of modified FOLFOX-6 neoadjuvant chemotherapy. The scheduled long-course radiotherapy (50Gy/25f) was ceased after the first time due to severe anal incontinence and myelosuppression. Laparoscopic abdominoperineal resection (R0) with a permanent colostomy was performed for her 6 weeks after the termination of neoadjuvant therapy . Guided by the fast-track surgery pathway, the patient’s recovery was uneventful, with discharge on postoperative day 5. The final diagnosis of rectal SRCC (ypT3N1bM0, Tumor Regression Grade 2) was determined via postoperative pathologic findings . Two out of eighteen mesorectal lymph nodes were identified with tumor involvement. Meanwhile, the proficient mismatch repair (MMR) was detected. The postoperative chemotherapy was consistent with the neoadjuvant regimen and initiated 4 weeks after surgery.\nAfter the second cycle of adjuvant modified FOLFOX-6, a painless, firm mass was palpable in the right breast and the area of vulva, respectively. The follow-up CT examination found the right breast mass . Ultrasound-guided core needle biopsies were performed for her. Hematoxylin & eosin and immunohistochemical (IHC) staining indicated the metastases to the breast (positive: CK20, CDX-2, E-cadherin; negative: CK7, PR, ER, Her-2, GATA3, GCDFP15) and vulva (positive: CDX-2, PCK, CEA, Alcian Blue) from rectal SRCC. In addition, genetic testing demonstrated RAS/BRAF wild-type and microsatellite instability-low (MSI-L).\nIn December 2018, metastases to bilateral lung have been developed and the evaluation of efficacy was identified as progressive disease. Then the chemotherapy regimen was changed to irinotecan (290mg, day1, q3w) plus tegafur (50mg bid, day1-14, q3w). However, multiple metastases throughout the body (including the left breast) were found 3 months later. Tegafur (50mg, bid, day1-14, q3w) plus raltitrexed (4mg, day1, q3w)-based chemotherapy in combination with bevacizumab (400mg, day1, q3w) as the third-line treatment did not provide favorable efficacy. Unfortunately, the patient passed away 15 months after initial diagnosis due to rapidly progressive disease. The results of serum tumor markers (CEA and CA19-9) are listed in . Though limited sensitivity, the reduction of tumor markers at the early phase represented favorable response to neoadjuvant therapy, while the elevation of tumor markers at the late phase indicated rapidly progressive disease. The timeline with clinical data from the episode of care is shown in .", + "fulltext_subclaims": [ + "The patient was a 26-year-old female.", + "She presented with anal pain, constipation, and hematochezia for approximately two years.", + "She had given birth two and a half years previously.", + "Digital rectal examination revealed an ulcerated 5-cm indurated lesion at the nine o’clock position and 2 cm from the anal verge.", + "The blood tests showed elevated carcinoembryonic antigen (CEA) (10.51 ng/ml; reference range, < 3.4 ng/ml).", + "The blood tests showed elevated carbohydrate antigen 19-9 (CA19-9) (40.49 U/ml; reference range, < 22 U/ml).", + "The diagnosis of poorly differentiated adenocarcinoma was established by flexible sigmoidoscopy with biopsies and histological examination.", + "Computed tomography (CT) of the chest and abdomen and magnetic resonance imaging (MRI) of the pelvic confirmed the tumor stage of cT3N1M0.", + "Radiologic examinations did not detect metastasis to the liver, bone, lung, or breast.", + "The patient underwent prophylactic transverse colostomy.", + "She received 6 cycles of modified FOLFOX-6 neoadjuvant chemotherapy.", + "The scheduled long-course radiotherapy was ceased after the first time due to severe anal incontinence and myelosuppression.", + "Laparoscopic abdominoperineal resection (R0) with a permanent colostomy was performed.", + "The final diagnosis of rectal SRCC (ypT3N1bM0, Tumor Regression Grade 2) was determined via postoperative pathologic findings.", + "Two out of eighteen mesorectal lymph nodes were identified with tumor involvement.", + "The proficient mismatch repair (MMR) was detected.", + "The postoperative chemotherapy was consistent with the neoadjuvant regimen.", + "The postoperative chemotherapy was initiated 4 weeks after surgery.", + "A painless, firm mass was palpable in the right breast and the area of vulva after the second cycle of adjuvant modified FOLFOX-6.", + "The follow-up CT examination found the right breast mass.", + "Ultrasound-guided core needle biopsies were performed.", + "Hematoxylin & eosin and immunohistochemical (IHC) staining indicated the metastases to the breast.", + "Hematoxylin & eosin and immunohistochemical (IHC) staining indicated the metastases to the vulva from rectal SRCC.", + "Genetic testing demonstrated RAS/BRAF wild-type.", + "Genetic testing demonstrated microsatellite instability-low (MSI-L).", + "Metastases to bilateral lung have been developed in December 2018.", + "The evaluation of efficacy was identified as progressive disease.", + "The chemotherapy regimen was changed to irinotecan (290mg, day1, q3w) plus tegafur (50mg bid, day1-14, q3w).", + "Multiple metastases throughout the body (including the left breast) were found 3 months later.", + "Tegafur (50mg, bid, day1-14, q3w) plus raltitrexed (4mg, day1, q3w)-based chemotherapy in combination with bevacizumab (400mg, day1, q3w) as the third-line treatment did not provide favorable efficacy.", + "The patient passed away 15 months after initial diagnosis due to rapidly progressive disease.", + "The reduction of tumor markers at the early phase represented favorable response to neoadjuvant therapy.", + "The elevation of tumor markers at the late phase indicated rapidly progressive disease." + ], + "summary": "A 26-year-old woman presented with progressively worsening anal pain, constipation, and hematochezia for approximately two years. Following the diagnosis of locally advanced rectal cancer (cT3N0-1M0), she received neoadjuvant chemotherapy with modified FOLFOX6 regimen and underwent laparoscopic abdominoperineal resection. Metastases to the breast and vulva developed during postoperative chemotherapy. Genetic testing revealed RAS/BRAF wild-type and microsatellite instability (MSI)-low status. Though sequential administration of irinotecan plus tegafur and tegafur plus raltitrexed-based chemotherapy in combination with bevacizumab, the disease progressed rapidly. Sadly, the patient passed away 15 months after initial diagnosis due to rapidly progressive disease.", + "summary_subclaims": [ + "The patient is a 26-year-old woman.", + "She had progressively worsening anal pain, constipation, and hematochezia for approximately two years.", + "She was diagnosed with locally advanced rectal cancer (cT3N0-1M0).", + "She received neoadjuvant chemotherapy with modified FOLFOX6 regimen.", + "She underwent laparoscopic abdominoperineal resection.", + "Metastases to the breast and vulva developed during postoperative chemotherapy.", + "Genetic testing revealed RAS/BRAF wild-type status.", + "Genetic testing revealed microsatellite instability (MSI)-low status.", + "She received sequential administration of irinotecan plus tegafur.", + "She received tegafur plus raltitrexed-based chemotherapy in combination with bevacizumab.", + "The disease progressed rapidly.", + "The patient passed away 15 months after initial diagnosis due to rapidly progressive disease." + ] + }, + { + "id": "multiclinsum_test_1862_en.txt", + "fulltext": "A 57 years-old male patient presented with back pain, general discomfort, polydipsia, polyuria, fatigue and recent weight loss of 10 kg. Clinical examination was normal and there was no relevant medical history. Biochemical evaluation showed hypercalcemia (2,85 mmol/L; normal: 2.15–2.55 mmol/L) with slightly lowered PTH levels (14,2 ng/L; normal 14,9–56,9 ng/L) excluding hyperparathyroidism. CT-thorax-abdomen and ultrasound guided biopsy revealed a pNET with multifocal liver metastases as well as some small bone lesions. The Ki-67 index was 15 to 20% compatible with a grade 2 tumor. PTHrP was normal and although our patient had some osteodense skeletal metastases, these bone lesions alone could not explain his marked hypercalcemia. However, markedly increased calcitriol levels up to 134.3 ng/L (normal: 20.0–80.0 ng/L) were detected. We hypothesized that overproduction of this active form of vitamin D by the pNET was the cause of the HCM.\nInitial treatment with lanreotide, a non-radioactive SSA, and everolimus, an inhibitor of mammalian target of rapamycin (mTOR), resulted in morphologically stable disease, but there was no effect on the hypercalcemia nor on the associated symptoms. The patient was evaluated for treatment with PRRT. In the meantime, therapy with FOLFOX chemotherapy was started. 68Ga-DOTATATE scan revealed intense SSR expression in the pancreatic lesion as well as strong uptake in the liver metastases and the skeletal metastases. All malignant lesions had an uptake intensity above the spleen (Krenning score grade 4) . 18F-FDG-PET/CT showed strong hypermetabolism in some of the liver metastases (metabolic grade 3) . There were no 18F-FDG + / SSR - mismatched lesions. Evaluation of the renal function showed no contraindication for therapy. Four cycles of PRRT with 177Lu-DOTATATE were given, with a treatment interval of 8 weeks up to a cumulative activity of 29.6 GBq. Three months after the final cycle, the initially refractory serum calcium levels had normalized and the associated symptoms disappeared , confirming the hypothesis of a calcitriol secreting pNET. Although there was a clear morphologic response , some liver lesions showed an increase in 18F-FDG uptake compared with baseline . Because of these signs of metabolic progression, the patient was started on temozolomide-capecitabine, which resulted in continued morphological disease stabilization as well as continued normal serum calcium and calcitriol.", + "fulltext_subclaims": [ + "The patient is a 57 years-old male.", + "The patient presented with back pain.", + "The patient presented with general discomfort.", + "The patient presented with polydipsia.", + "The patient presented with polyuria.", + "The patient had recent weight loss of 10 kg.", + "Clinical examination was normal.", + "There was no relevant medical history.", + "Biochemical evaluation showed hypercalcemia (2,85 mmol/L; normal: 2.15–2.55 mmol/L).", + "CT-thorax-abdomen and ultrasound guided biopsy revealed a pNET with multifocal liver metastases.", + "The Ki-67 index was 15 to 20%.", + "The Ki-67 index was compatible with a grade 2 tumor.", + "Markedly increased calcitriol levels up to 134.3 ng/L (normal: 20.0–80.0 ng/L) were detected.", + "We hypothesized that overproduction of this active form of vitamin D by the pNET was the cause of the HCM.", + "Initial treatment with lanreotide and everolimus resulted in morphologically stable disease.", + "There was no effect on the hypercalcemia.", + "There was no effect on the associated symptoms.", + "The patient was evaluated for treatment with PRRT.", + "Therapy with FOLFOX chemotherapy was started.", + "68Ga-DOTATATE scan revealed intense SSR expression in the pancreatic lesion.", + "68Ga-DOTATATE scan revealed strong uptake in the liver metastases.", + "68Ga-DOTATATE scan revealed strong uptake in the skeletal metastases.", + "All malignant lesions had an uptake intensity above the spleen (Krenning score grade 4).", + "18F-FDG-PET/CT showed strong hypermetabolism in some of the liver metastases (metabolic grade 3).", + "There were no 18F-FDG + / SSR - mismatched lesions.", + "Evaluation of the renal function showed no contraindication for therapy.", + "Four cycles of PRRT with 177Lu-DOTATATE were given.", + "The treatment interval was 8 weeks.", + "The cumulative activity was 29.6 GBq.", + "Three months after the final cycle, the initially refractory serum calcium levels had normalized.", + "The associated symptoms disappeared.", + "There was a clear morphologic response.", + "Some liver lesions showed an increase in 18F-FDG uptake compared with baseline.", + "The patient was started on temozolomide-capecitabine.", + "Temozolomide-capecitabine resulted in continued morphological disease stabilization.", + "Temozolomide-capecitabine resulted in continued normal serum calcium.", + "Temozolomide-capecitabine resulted in continued normal calcitriol." + ], + "summary": "A 57 years-old patient presented with back pain, general discomfort, polydipsia, polyuria, fatigue and recent weight loss of 10 kg. Clinical examination was normal and there was no relevant medical history. Biochemical evaluation showed hypercalcemia with markedly increased calcitriol levels. CT-thorax-abdomen and ultrasound guided biopsy revealed a pancreatic neuroendocrine tumor with multifocal liver metastases, suggesting that excessive overproduction of calcitriol by this neuroendocrine tumor was the cause of the refractory hypercalcemia. The patient was eligible for PRRT. Four cycles of 177Lu-DOTATATE PRRT resulted in a morphological response and a normalization of serum calcium levels, confirming the hypothesis of a calcitriol producing pancreatic neuroendocrine tumor. Progression of liver metastases warranted further therapy and temozolomide-capecitabine was started with morphological and biochemical (serum calcium, calcitriol) stabilization.", + "summary_subclaims": [ + "The patient was a 57 years-old.", + "The patient reported back pain.", + "The patient reported general discomfort.", + "The patient reported polydipsia.", + "The patient reported polyuria.", + "The patient reported fatigue.", + "The patient had a recent weight loss of 10 kg.", + "Clinical examination was normal.", + "There was no relevant medical history.", + "Biochemical evaluation showed hypercalcemia.", + "Biochemical evaluation showed markedly increased calcitriol levels.", + "CT-thorax-abdomen and ultrasound guided biopsy revealed a pancreatic neuroendocrine tumor.", + "CT-thorax-abdomen and ultrasound guided biopsy revealed multifocal liver metastases.", + "Excessive overproduction of calcitriol by this neuroendocrine tumor was the cause of the refractory hypercalcemia.", + "The patient was eligible for PRRT.", + "Four cycles of 177Lu-DOTATATE PRRT resulted in a morphological response.", + "Four cycles of 177Lu-DOTATATE PRRT resulted in a normalization of serum calcium levels.", + "The hypothesis of a calcitriol producing pancreatic neuroendocrine tumor was confirmed.", + "Progression of liver metastases warranted further therapy.", + "Temozolomide-capecitabine was started.", + "Temozolomide-capecitabine resulted in morphological and biochemical stabilization." + ] + }, + { + "id": "multiclinsum_test_3330_en.txt", + "fulltext": "The patient was a 95-year-old woman with a history of basal cell carcinoma in the right zygomatic region, which was surgically removed. She subsequently received radiotherapy for local recurrence. In addition, the patient was under palliative treatment and follow-up for an underlying chronic lymphoid leukemia. The patient presented to the emergency department of the José Carrasco Arteaga Hospital, Cuenca, Ecuador, for a history of increasing pain, pruritus and discharge in the right zygomatic region of a few days of evolution. On physical examination she was in regular general condition, conscious and oriented all three spheres; BP: 110/70, heart rate: 110 bpm, respiratory rate: 20 rpm, temperature: 38°C. A 5×5 cm cavitated lesion with necrotic margins surrounded by edematous hyperemic skin was observed in the right zygomatic-malar region with necrotic margins with foul-smelling purulent discharge and apparent bone involvement. Upon simple inspection, numerous fly larvae were observed embedded at the bottom of the skin cavity. The ipsilateral eye showed conjunctival injection and yellowish discharge.\n\nThe patient was readmitted with the diagnosis of myiasis, facial cellulitis and conjunctivitis for administration of intravenous antibiotics and antiparasitic treatment with ivermectin. Surgical debridement was performed with removal of all larvae, whose macroscopic taxonomic characteristics matched those of Cochliomyia hominivorax. Improvement of the lesion under inpatient treatment was observed in the following days. Plastic surgical repair of the cavitated lesion was considered as most probably unsuccessful due to advanced age, increased surgical risk, history of basal cell carcinoma, underlying chronic leukemia and overall poor mid-term prognosis.", + "fulltext_subclaims": [ + "The patient was a 95-year-old woman.", + "She had a history of basal cell carcinoma in the right zygomatic region.", + "The basal cell carcinoma was surgically removed.", + "She received radiotherapy for local recurrence.", + "The patient was under palliative treatment and follow-up for chronic lymphoid leukemia.", + "She presented to the emergency department of the José Carrasco Arteaga Hospital, Cuenca, Ecuador.", + "She had a history of increasing pain, pruritus, and discharge in the right zygomatic region.", + "The symptoms had a few days of evolution.", + "On physical examination, she was in regular general condition.", + "A 5×5 cm cavitated lesion with necrotic margins was observed in the right zygomatic-malar region.", + "The lesion had foul-smelling purulent discharge.", + "Numerous fly larvae were observed embedded at the bottom of the skin cavity.", + "The diagnosis was myiasis.", + "The diagnosis included facial cellulitis.", + "The diagnosis included conjunctivitis.", + "Surgical debridement was performed.", + "All larvae were removed.", + "The larvae's macroscopic taxonomic characteristics matched those of Cochliomyia hominivorax.", + "Plastic surgical repair of the cavitated lesion was considered.", + "Plastic surgical repair was considered as most probably unsuccessful." + ], + "summary": "The current case involves a 95-year-old woman, an inhabitant of the Andean region of Ecuador with a history of resection of basal cell carcinoma in the left zygomatic region and a diagnosis of chronic leukemia. The surgical wound was secondarily infested with Cochliomyia hominivorax fly larvae and the patient was readmitted to the hospital to treat this complication. A marked clinical improvement was observed after surgical debridement, removal of larvae and administration of ivermectin and antibiotics.", + "summary_subclaims": [ + "The patient is a 95-year-old woman.", + "The patient is an inhabitant of the Andean region of Ecuador.", + "The patient has a history of resection of basal cell carcinoma in the left zygomatic region.", + "The patient has a diagnosis of chronic leukemia.", + "The surgical wound was secondarily infested with Cochliomyia hominivorax fly larvae.", + "The patient was readmitted to the hospital to treat this complication.", + "A marked clinical improvement was observed after surgical debridement.", + "A marked clinical improvement was observed after removal of larvae.", + "A marked clinical improvement was observed after administration of ivermectin and antibiotics." + ] + }, + { + "id": "multiclinsum_test_312_en.txt", + "fulltext": "A 49-year-old man (122.9 kg, BMI 39.1 kg/m2) presented to our hospital wishing to undergo LSG and VHR. His medical history included diabetes mellitus, hypertension, and hyperlipidemia. He had undergone urgent surgery for an umbilical hernia with incarcerated small bowel 18 months ago. The surgery included small bowel resection and direct closure of the defect without mesh reinforcement. Six months later, the umbilical hernia recurred. Physical examination revealed a tennis ball-sized lower midline defect. Computed tomography (CT) scans revealed a hernia orifice 5 cm in width and 10 cm in height in the infra-umbilical region . As mesh reinforcement was essential to repair the ventral hernia, we planned for him to undergo VHR after LSG.\nLSG was performed using a standardized surgical technique with a 37.5 Fr bougie. Intraoperative findings revealed adhesion between the omentum and the hernia sac, which was not dissected during LSG. His postoperative course was uneventful, and after 9 months, he showed satisfactory weight loss (84.2 kg, BMI 26.8 kg/m2) and his comorbidities such as diabetes mellitus, hypertension, and hyperlipidemia were in remission. We then performed VHR using the eTEP technique.\nAfter induction of general anesthesia and intubation, he was positioned with the bilateral upper extremities tucked at his sides. Figure shows the port placement in this case. A 1.5-cm skin incision was made just below the left costal margin, and the anterior rectus sheath was identified and incised sharply. A 12-mm trocar was inserted posterior to the rectus abdominis muscle, and the left retrorectus space was developed followed by insertion of two 5-mm trocars at the port 2 and port 3 positions medial to the linea semilunaris. The left posterior rectus sheath was incised close to the linea alba, and then the right posterior rectus sheath was opened over the falciform ligament. After the preperitoneal and two retrorectus spaces were connected, a 12-mm trocar was inserted at port 4, and lateral dissection of the right posterior rectus sheath was done. Two 5-mm trocars were inserted at the port 5 and port 6 positions. The sac was opened, and intraabdominal adhesions were dissected . Bilateral transversus abdominis muscle release was performed . The posterior layer defect was closed with 3-0 multifilament suture material . Then, the linea alba was restored with 1-0 barbed sutures . BARD™ Mesh (Davol Inc., Warwick, RI, USA 02,886), a medium-weight small-pore (0.44 mm) polypropylene mesh of 26 cm width × 35.5 cm height, was positioned to cover the dissected area with no fixation . A 19 Fr drain was placed over the mesh. The operating time was 452 min, and the amount of blood loss was nearly 0 g. The patient’s postoperative course was uneventful, the drain was removed 4 days after the surgery, and he was discharged on the same day. A CT scan 4 months after eTEP repair did not show recurrence or seroma . At 1-year follow-up, he was doing well.", + "fulltext_subclaims": [ + "The patient is a 49-year-old man.", + "The patient's weight was 122.9 kg.", + "The patient's BMI was 39.1 kg/m2.", + "The patient wished to undergo LSG and VHR.", + "The patient's medical history included diabetes mellitus.", + "The patient's medical history included hypertension.", + "The patient's medical history included hyperlipidemia.", + "The patient had undergone urgent surgery for an umbilical hernia with incarcerated small bowel 18 months ago.", + "The surgery included small bowel resection.", + "The surgery included direct closure of the defect without mesh reinforcement.", + "Six months after the surgery, the umbilical hernia recurred.", + "Physical examination revealed a tennis ball-sized lower midline defect.", + "Computed tomography (CT) scans revealed a hernia orifice 5 cm in width.", + "Computed tomography (CT) scans revealed a hernia orifice 10 cm in height.", + "The hernia orifice was located in the infra-umbilical region.", + "Mesh reinforcement was essential to repair the ventral hernia.", + "The patient planned to undergo VHR after LSG.", + "LSG was performed using a standardized surgical technique with a 37.5 Fr bougie.", + "Intraoperative findings revealed adhesion between the omentum and the hernia sac.", + "The adhesion was not dissected during LSG.", + "The patient's postoperative course was uneventful.", + "After 9 months, the patient showed satisfactory weight loss.", + "After 9 months, the patient's weight was 84.2 kg.", + "After 9 months, the patient's BMI was 26.8 kg/m2.", + "After 9 months, the patient's comorbidities were in remission.", + "The patient then underwent VHR using the eTEP technique.", + "A 1.5-cm skin incision was made just below the left costal margin.", + "The anterior rectus sheath was identified and incised sharply.", + "A 12-mm trocar was inserted posterior to the rectus abdominis muscle.", + "The left retrorectus space was developed.", + "Two 5-mm trocars were inserted at the port 2 and port 3 positions medial to the linea semilunaris.", + "The left posterior rectus sheath was incised close to the linea alba.", + "The right posterior rectus sheath was opened over the falciform ligament.", + "After the preperitoneal and two retrorectus spaces were connected, a 12-mm trocar was inserted at port 4.", + "Lateral dissection of the right posterior rectus sheath was done.", + "Two 5-mm trocars were inserted at the port 5 and port 6 positions.", + "The sac was opened.", + "Intraabdominal adhesions were dissected.", + "Bilateral transversus abdominis muscle release was performed.", + "The posterior layer defect was closed with 3-0 multifilament suture material.", + "The linea alba was restored with 1-0 barbed sutures.", + "BARD™ Mesh was positioned to cover the dissected area.", + "The mesh was not fixed.", + "A 19 Fr drain was placed over the mesh.", + "The operating time was 452 min.", + "The amount of blood loss was nearly 0 g.", + "The patient’s postoperative course was uneventful.", + "The drain was removed 4 days after the surgery.", + "The patient was discharged on the same day.", + "A CT scan 4 months after eTEP repair did not show recurrence.", + "A CT scan 4 months after eTEP repair did not show seroma.", + "At 1-year follow-up, the patient was doing well." + ], + "summary": "A 49-year-old man (122.9 kg, BMI 39.1 kg/m2) presented to our hospital wishing to undergo laparoscopic sleeve gastrectomy and VHR. Physical examination revealed a tennis ball-sized lower midline defect. Computed tomography (CT) scans revealed a hernia orifice 5 cm in width and 10 cm in height. As the hernia orifice was large, mesh reinforcement was essential. We planned for him to undergo VHR after massive weight loss was achieved by MBS. VHR was performed using the enhanced-view totally extraperitoneal (eTEP) technique after weight loss of 38 kg was achieved 9 months following laparoscopic sleeve gastrectomy. His postoperative course was uneventful, and neither recurrence nor seroma was observed at 1 year follow-up.", + "summary_subclaims": [ + "The patient is a 49-year-old man.", + "The patient's BMI was 39.1 kg/m2.", + "The patient wished to undergo laparoscopic sleeve gastrectomy.", + "The patient wished to undergo VHR.", + "Physical examination revealed a tennis ball-sized lower midline defect.", + "Computed tomography (CT) scans revealed a hernia orifice 5 cm in width.", + "Computed tomography (CT) scans revealed a hernia orifice 10 cm in height.", + "Mesh reinforcement was essential.", + "We planned for the patient to undergo VHR after massive weight loss was achieved by MBS.", + "VHR was performed using the enhanced-view totally extraperitoneal (eTEP) technique.", + "Weight loss of 38 kg was achieved 9 months following laparoscopic sleeve gastrectomy.", + "The postoperative course was uneventful.", + "Neither recurrence nor seroma was observed at 1 year follow-up." + ] + }, + { + "id": "multiclinsum_test_1705_en.txt", + "fulltext": "A 70-year-old female with a history of primary angle closure glaucoma (PACG) status post laser peripheral iridotomy (PI) of both eyes (OU) presented for further management. She complained of discomfort and redness of the right eye (OD). Past medical history was significant for hypertension, gastroesophageal reflux disease and a cerebrovascular accident 15 years prior. Medications included atenolol, alprazolam, omeprazole, aspirin and topical prednisolone four times a day OD. The duration of topical prednisolone treatment was approximately 1 week prior to her presentation to our institution. The treatment was deemed necessary by the referring physician for her complaint of discomfort and redness. No other topical medications were given. Intraocular pressure (IOP) was 22 OD and 16 of the left eye (OS). Exam showed mild injection OD, shallow anterior chambers, patent PIs and cataracts OU. Gonioscopy demonstrated narrow angles with extensive peripheral anterior synechiae OU. Dilated fundus exam showed increased vessel tortuosity OU.\nGiven the significant narrow angles despite patent PIs OU, cataract extraction with intraocular lens implantation OU was performed. She was treated postoperatively with topical moxifloxacin, nepafenac and prednisolone for a month. She did not receive dorzolamide or other sulfa derivatives. Postoperatively, the anterior chambers deepened and the angles opened significantly. IOP was noted to be 19 OD and 18 OS. No hypotony was detected throughout the entire course.\nTwo months after cataract surgery, she developed 4 mm of proptosis, resistance to retropulsion, tortuous corkscrew blood vessels and an orbital bruit OD. Gonioscopy revealed the recurrence of narrow angles OD.\nA CCF was suspected and both computed tomography (CT) of the orbits with and without contrast and computed tomography angiography (CTA) of the head were performed. The CT orbits showed possible asymmetry of the superior ophthalmic veins (SOV). The CTA head showed atherosclerotic disease within the distal cavernous segments of the internal carotid arteries. As neither imaging modality was completely diagnostic and high suspicion for a CCF remained (based on the clinical examination findings), a six vessel cerebral angiogram was performed. The diagnostic cerebral angiogram showed a small indirect Barrow type D right carotid cavernous fistula with retrograde drainage into the right SOV . Early filling of the right SOV was seen on right internal carotid artery injection; however, there were no feeders large enough to be actually visualized. On injection of the right external carotid artery, there was filling of the cavernous sinus via small branches of the right accessory meningeal artery. Our patient did not have a suitable endovascular corridor to the CCF via the petrosal sinuses, therefore transfemoral venous embolization did not appear possible. The plan was for transarterial embolization and if satisfactory occlusion could not be achieved from embolization of the right accessory meningeal artery feeder, then an alternative approach through the right SOV was to be considered. When diagnostic cerebral angiography was repeated prior to the planed embolization procedure, it was noted that she had undergone spontaneous partial closure of her CCF and the procedure was aborted.\nOne month later, our patient developed worsening vision and was noted to have a choroidal detachment OD . She declined further angiographic testing and was thus started on self-administered manual carotid jugular compressions. One month later, she was noted to have progressive worsening of her choroidal detachments and angle closure .\nShe eventually opted for repeat surgical intervention but when diagnostic cerebral angiography was performed prior to the embolization procedure, significant thrombosis of the CCF was noted. There was virtually no filling of the SOV on angiography and no intervention was warranted. Examination two months later showed complete resolution of her choroidal detachments and open angles OU.", + "fulltext_subclaims": [ + "The patient is a 70-year-old female.", + "She has a history of primary angle closure glaucoma.", + "She had laser peripheral iridotomy of both eyes.", + "She presented with discomfort and redness of the right eye.", + "Her past medical history includes hypertension.", + "Her past medical history includes gastroesophageal reflux disease.", + "She had a cerebrovascular accident 15 years prior.", + "She was taking atenolol.", + "She was taking alprazolam.", + "She was taking omeprazole.", + "She was taking aspirin.", + "She was using topical prednisolone four times a day in the right eye.", + "The duration of topical prednisolone treatment was approximately 1 week prior to her presentation.", + "The treatment was deemed necessary by the referring physician.", + "Intraocular pressure was 22 in the right eye.", + "Intraocular pressure was 16 in the left eye.", + "Exam showed mild injection in the right eye.", + "Gonioscopy demonstrated narrow angles with extensive peripheral anterior synechiae in both eyes.", + "Dilated fundus exam showed increased vessel tortuosity in both eyes.", + "Cataract extraction with intraocular lens implantation was performed in both eyes.", + "She was treated postoperatively with topical moxifloxacin.", + "She was treated postoperatively with topical nepafenac.", + "She was treated postoperatively with topical prednisolone for a month.", + "She did not receive dorzolamide.", + "Postoperatively, the anterior chambers deepened.", + "Postoperatively, the angles opened significantly.", + "Intraocular pressure was 19 in the right eye.", + "Intraocular pressure was 18 in the left eye.", + "No hypotony was detected.", + "Two months after cataract surgery, she developed 4 mm of proptosis in the right eye.", + "Gonioscopy revealed the recurrence of narrow angles in the right eye.", + "A carotid cavernous fistula was suspected.", + "Computed tomography of the orbits with and without contrast was performed.", + "Computed tomography angiography of the head was performed.", + "The CT orbits showed possible asymmetry of the superior ophthalmic veins.", + "The CTA head showed atherosclerotic disease within the distal cavernous segments of the internal carotid arteries.", + "A six vessel cerebral angiogram was performed.", + "The diagnostic cerebral angiogram showed a small indirect Barrow type D right carotid cavernous fistula.", + "Early filling of the right superior ophthalmic vein was seen on right internal carotid artery injection.", + "There were no feeders large enough to be actually visualized.", + "On injection of the right external carotid artery, there was filling of the cavernous sinus via small branches of the right accessory meningeal artery.", + "The patient did not have a suitable endovascular corridor to the CCF via the petrosal sinuses.", + "Transfemoral venous embolization did not appear possible.", + "The plan was for transarterial embolization.", + "When diagnostic cerebral angiography was repeated prior to the planned embolization procedure, it was noted that she had undergone spontaneous partial closure of her CCF.", + "The procedure was aborted.", + "One month later, the patient developed worsening vision.", + "She was noted to have a choroidal detachment in the right eye.", + "She declined further angiographic testing.", + "She was started on self-administered manual carotid jugular compressions.", + "One month later, she was noted to have progressive worsening of her choroidal detachments.", + "She eventually opted for repeat surgical intervention.", + "When diagnostic cerebral angiography was performed prior to the embolization procedure, significant thrombosis of the CCF was noted.", + "There was virtually no filling of the superior ophthalmic vein on angiography.", + "No intervention was warranted.", + "Examination two months later showed complete resolution of her choroidal detachments.", + "Examination two months later showed open angles in both eyes." + ], + "summary": "A 70-year-old female with a history of primary angle closure glaucoma presented with 4 mm of proptosis, resistance to retropulsion, tortuous corkscrew blood vessels and an orbital bruit of the right eye. Diagnostic cerebral angiogram showed a small indirect Barrow type D right carotid cavernous fistula. Transarterial embolization was planned but repeat cerebral angiography prior to the procedure demonstrated spontaneous partial closure of the carotid cavernous fistula and the procedure was aborted. One month later, our patient was noted to have worsening vision and choroidal detachments of the right eye. She declined further testing and was thus started on self-administered manual carotid jugular compressions. One month later, she developed progressive worsening of her choroidal detachments and angle closure. She eventually opted for surgical intervention but repeat cerebral angiography showed significant thrombosis of the carotid cavernous fistula and no intervention was warranted. Examination two months later showed complete resolution of the choroidal detachments and open angles of both eyes.", + "summary_subclaims": [ + "The patient is a 70-year-old female.", + "The patient has a history of primary angle closure glaucoma.", + "The patient had 4 mm of proptosis of the right eye.", + "The patient had resistance to retropulsion of the right eye.", + "The patient had tortuous corkscrew blood vessels of the right eye.", + "The patient had an orbital bruit of the right eye.", + "A diagnostic cerebral angiogram showed a small indirect Barrow type D right carotid cavernous fistula.", + "Transarterial embolization was planned.", + "Repeat cerebral angiography prior to the procedure demonstrated spontaneous partial closure of the carotid cavernous fistula.", + "The planned procedure was aborted.", + "One month later, the patient was noted to have worsening vision of the right eye.", + "One month later, the patient had choroidal detachments of the right eye.", + "The patient declined further testing.", + "The patient was started on self-administered manual carotid jugular compressions.", + "One month later, the patient developed progressive worsening of her choroidal detachments.", + "One month later, the patient had angle closure.", + "The patient opted for surgical intervention.", + "Repeat cerebral angiography showed significant thrombosis of the carotid cavernous fistula.", + "No intervention was warranted.", + "Examination two months later showed complete resolution of the choroidal detachments.", + "Examination two months later showed open angles of both eyes." + ] + }, + { + "id": "multiclinsum_test_1641_en.txt", + "fulltext": "An 11-year-old girl presented to another hospital with lower abdominal pain and vomiting that lasted for 2 days. Acute appendicitis was suspected, and she was referred to our department. On initial physical examination, her body temperature was 38.2 °C, and pulse and blood pressure were within normal ranges. Her abdomen was soft and mildly distended with tenderness localized to the lower abdomen. Laboratory data showed elevated levels of white blood cells (1.29 × 104/μl) and C-reactive protein (3.69 mg/dl). Hemoglobin level was normal (14.1 g/dl). Abdominal enhanced computed tomography showed an abscess in the lower abdomen with ascites in the pelvis . The patient was diagnosed with a localized intra-abdominal abscess and the decision was made to treat with antibiotics. However, her abdominal pain worsened, with abdominal distension, tenderness, and muscle guarding. She was diagnosed with panperitonitis and underwent surgery 5 h after admission. Laparoscopic observation from the umbilical region revealed 200 ml of fresh blood throughout the peritoneal cavity . The appendix looked normal, and the possibility of acute appendicitis was unlikely. Therefore, the umbilical incision was extended to identify a bleeding site, and an MD was detected associated with mesenteric bleeding . During surgery, the exact perforation point was undetectable. Small bowel resection was performed, and she was discharged without complication on the 5th postoperative day.\nGross inspection of the resected specimen revealed an ileal perforation adjacent to MD junction . Microscopically, the ileum had a peptic ulcer that perforated muscular layer. The MD mucosa in the vicinity of the junction was composed of ectopic gastric glands, and foveolar epithelia were filled with gastric juice .", + "fulltext_subclaims": [ + "An 11-year-old girl presented to another hospital with lower abdominal pain and vomiting that lasted for 2 days.", + "Acute appendicitis was suspected, and she was referred to our department.", + "On initial physical examination, her body temperature was 38.2 °C.", + "Her abdomen was soft and mildly distended with tenderness localized to the lower abdomen.", + "Laboratory data showed elevated levels of white blood cells (1.29 × 104/μl) and C-reactive protein (3.69 mg/dl).", + "Abdominal enhanced computed tomography showed an abscess in the lower abdomen with ascites in the pelvis.", + "The patient was diagnosed with a localized intra-abdominal abscess.", + "The decision was made to treat with antibiotics.", + "Her abdominal pain worsened, with abdominal distension, tenderness, and muscle guarding.", + "She was diagnosed with panperitonitis.", + "She underwent surgery 5 h after admission.", + "Laparoscopic observation from the umbilical region revealed 200 ml of fresh blood throughout the peritoneal cavity.", + "The appendix looked normal.", + "The possibility of acute appendicitis was unlikely.", + "The umbilical incision was extended to identify a bleeding site.", + "An MD was detected associated with mesenteric bleeding.", + "During surgery, the exact perforation point was undetectable.", + "Small bowel resection was performed.", + "She was discharged without complication on the 5th postoperative day.", + "Gross inspection of the resected specimen revealed an ileal perforation adjacent to MD junction.", + "Microscopically, the ileum had a peptic ulcer that perforated muscular layer.", + "The MD mucosa in the vicinity of the junction was composed of ectopic gastric glands.", + "The foveolar epithelia were filled with gastric juice." + ], + "summary": "An 11-year-old girl presented to another hospital with lower abdominal pain and vomiting that lasted for 2 days. Acute appendicitis was suspected, and she was referred to our department. Abdominal enhanced computed tomography showed an abscess in the lower abdomen with ascites in the pelvis. She was diagnosed with a localized intra-abdominal abscess and the decision was made to treat with antibiotics. However, her abdominal pain worsened, with abdominal distension, tenderness and guarding. She was diagnosed with panperitonitis and the decision was made for surgery 5 h after admission. During surgery, laparoscopic observation from the umbilical region revealed 200 ml of fresh blood throughout the peritoneal cavity, originating from the mesentery of the ileum. MD was observed with bleeding from the surrounding mesentery. Small bowel resection was performed, and the patient was discharged on the 5th postoperative day. Pathological findings revealed an MD containing ectopic gastric mucosa and small intestinal ulcer perforation at the base of the MD.", + "summary_subclaims": [ + "An 11-year-old girl presented to another hospital with lower abdominal pain and vomiting that lasted for 2 days.", + "Acute appendicitis was suspected, and she was referred to our department.", + "Abdominal enhanced computed tomography showed an abscess in the lower abdomen with ascites in the pelvis.", + "She was diagnosed with a localized intra-abdominal abscess.", + "The decision was made to treat with antibiotics.", + "Her abdominal pain worsened, with abdominal distension, tenderness and guarding.", + "She was diagnosed with panperitonitis.", + "The decision was made for surgery 5 h after admission.", + "During surgery, laparoscopic observation from the umbilical region revealed 200 ml of fresh blood throughout the peritoneal cavity.", + "The blood was originating from the mesentery of the ileum.", + "MD was observed with bleeding from the surrounding mesentery.", + "Small bowel resection was performed.", + "The patient was discharged on the 5th postoperative day.", + "Pathological findings revealed an MD containing ectopic gastric mucosa.", + "Small intestinal ulcer perforation was found at the base of the MD." + ] + }, + { + "id": "multiclinsum_test_1736_en.txt", + "fulltext": "A 34-year old African-American woman presented with a giant perineal tumor associated with a 29-year history of keloid formation without recalled dermal injury or abrasion. The patient's history revealed two family members (a mother and sister) with similar symptomology, resulting in a diagnosis of familial keloid syndrome. However, neither the mother nor sister was affected with perineal keloid development. Past medical history was also notable for arthritic symptoms and diabetes mellitus, which were present in both mother and sister. The index lesion was firm, pliable growth, 20 cm in its greatest diameter, adjacent to 10 cm and 6 cm perivulvar lesions, which caused the patient considerable discomfort and affected ambulation . Physical examination revealed multiple other hypertrophic nodular growths on the posterior neck, behind the right ear, bilateral scapular regions, right flank and breast, abdomen and extremities in addition to the primary lesion. Past medical history evinced numerous heterogeneous treatments for various keloids in multiple loci; she had previously received surgical extirpation, steroid injections, and two episodes of radiotherapy to the back. Despite these interventions, her keloids have either recurred or persisted. Surgical extirpation of the largest perineal lesion was undertaken, and histopathologic examination was performed, denoting the classic keloid-associated features of haphazard collagen deposition, with nodular formations thickened hyalinized bands .\nOn the day following surgical excision, the patient was treated with radiotherapy using photons at 6MV. The total dose delivered was 22 Gy in 11 days, with a daily fraction of 2 Gy. The dose fraction was split between two fields with an anterior-posterior/posterior-anterior (AP/PA) port arrangement. Maximum acute Radiation Therapy Oncology Group skin toxicity score was Grade 3 (moderate ulceration and skin breakdown), which resolved after a 3-day treatment break.\nAt 6 months post-therapy, the lesion in question had not recurred , and the patient reported no difficulty attributable to the lesion.\nAfter 10 months after completion of radiation treatment for perineal keloids, the patient returned for additional treatment to her back and chest wall. Radiotherapy was delivered at 3 Gy/fraction with 9MeV electrons to her back, lateral back, and anteromedial back over 4 days. No complications have been noted, and the patient is currently being followed, with > 24 months since therapy..", + "fulltext_subclaims": [ + "The patient is a 34-year old African-American woman.", + "The patient presented with a giant perineal tumor.", + "The patient has a 29-year history of keloid formation.", + "The patient did not recall any dermal injury or abrasion.", + "The patient's mother and sister had similar symptomology.", + "The patient's mother and sister were not affected with perineal keloid development.", + "The patient's past medical history included arthritic symptoms.", + "The patient's past medical history included diabetes mellitus.", + "The index lesion was 20 cm in its greatest diameter.", + "The index lesion was adjacent to 10 cm and 6 cm perivulvar lesions.", + "The index lesion caused the patient considerable discomfort.", + "The index lesion affected ambulation.", + "Physical examination revealed multiple other hypertrophic nodular growths on the posterior neck.", + "Physical examination revealed multiple other hypertrophic nodular growths behind the right ear.", + "Physical examination revealed multiple other hypertrophic nodular growths on the bilateral scapular regions.", + "Physical examination revealed multiple other hypertrophic nodular growths on the right flank and breast.", + "Physical examination revealed multiple other hypertrophic nodular growths on the abdomen and extremities.", + "The patient had previously received surgical extirpation for keloids.", + "The patient had previously received steroid injections for keloids.", + "The patient had previously received two episodes of radiotherapy to the back.", + "Surgical extirpation of the largest perineal lesion was undertaken.", + "Histopathologic examination denoted classic keloid-associated features.", + "Histopathologic examination showed haphazard collagen deposition.", + "Histopathologic examination showed nodular formations.", + "Histopathologic examination showed thickened hyalinized bands.", + "On the day following surgical excision, the patient was treated with radiotherapy using photons at 6MV.", + "The total dose delivered was 22 Gy in 11 days.", + "The daily fraction was 2 Gy.", + "The dose fraction was split between two fields with an anterior-posterior/posterior-anterior port arrangement.", + "Maximum acute Radiation Therapy Oncology Group skin toxicity score was Grade 3.", + "Grade 3 toxicity resolved after a 3-day treatment break.", + "At 6 months post-therapy, the lesion had not recurred.", + "At 6 months post-therapy, the patient reported no difficulty attributable to the lesion.", + "After 10 months after completion of radiation treatment for perineal keloids, the patient returned for additional treatment.", + "Radiotherapy was delivered at 3 Gy/fraction with 9MeV electrons.", + "Radiotherapy was delivered to the back, lateral back, and anteromedial back over 4 days.", + "No complications have been noted.", + "The patient is currently being followed.", + "The patient has had > 24 months since therapy." + ], + "summary": "We present a patient with a history of recurrent keloids arising in the absence of an ascribed trauma and a maternal familial history of keloid formation, whose physical examination several large perineal keloids of 6-20 cm in the largest dimension. The patient was treated with surgical extirpation and adjuvant radiation therapy. Radiotherapy was delivered to the scar bed to a total dose of 22 Gy over 11 daily fractions. Acute radiotherapy toxicity necessitated a treatment break due to RTOG Grade III acute toxicity (moderate ulceration and skin breakdown) which resolved rapidly during a 3-day treatment break. The patient demonstrated local control and has remained free of local recurrence for more than 2 years.", + "summary_subclaims": [ + "The patient had a history of recurrent keloids arising in the absence of an ascribed trauma.", + "The patient had a maternal familial history of keloid formation.", + "Physical examination revealed several large perineal keloids of 6-20 cm in the largest dimension.", + "The patient was treated with surgical extirpation and adjuvant radiation therapy.", + "Radiotherapy was delivered to the scar bed to a total dose of 22 Gy over 11 daily fractions.", + "Acute radiotherapy toxicity necessitated a treatment break due to RTOG Grade III acute toxicity.", + "The RTOG Grade III acute toxicity was moderate ulceration and skin breakdown.", + "The acute toxicity resolved rapidly during a 3-day treatment break.", + "The patient demonstrated local control.", + "The patient has remained free of local recurrence for more than 2 years." + ] + }, + { + "id": "multiclinsum_test_1772_en.txt", + "fulltext": "An 80-year-old man was admitted to our institute for lower urinary tract symptoms (LUTS) in April 2018. International Prostate Symptom Score (IPSS) of the patient was evaluated as 30, while Quality of life (QoL) was scored as 5 points and Eastern Cooperative Oncology Group (ECOG) performance status was 0. Digital rectal examination revealed a grade III enlarged prostate, with palpable hard nodules on the surface obviously and the central sulcus disappeared. The value of serum prostate- specific antigen (PSA) was 145.6 ng/mL (normal value: 0–4 ng/mL), testosterone (T) was 354.5 ng/dl (normal value: 193–740 ng/dl), hemoglobin (Hb) was 119 g/l (normal value: 130–175 g/l), serum creatinine (SCr) was 67 μmol/l (normal range: 57–111 μmol/l). The pelvic enhanced magnetic resonance imaging (MRI) showed that a high possibility of prostate cancer, and the seminal vesicles and pelvic bones were invaded . Single-photon emission computed tomography (SPECT) indicated tumor had metastasized to multiple bones including the right ilium and the right sacroiliac joint . Transrectal ultrasound-guided biopsy revealed poorly differentiated AdPC after pathological examination, with a Gleason score of 9 (4 + 5), PSA (+), synaptophysin (-), chromogranin A (-) and Ki67 (15%) . The clinical stage was determined as stage IV (T3b N0 M1b) and this patient agreed to accept the ADT comprising bicalutamide (50 mg, once a day) combined with goserelin (10.8 mg, once every three months) since April 2018. The patient had a good response to the aforementioned therapy with the LUTS improved (IPSS 15, QoL 3) and serum PSA level decreased to 0.077 ng/mL (normal value: 0–4 ng/mL). Meanwhile, subsequent pelvic enhanced MRI and SPECT suggested the volume of the primary tumor and metastases was significantly reduced at the follow-up in June 2019.\nHowever, 6 months later, the patient gradually presented with gross hematuria, urination pain, anemia, tachycardia and pale lips, and thus was admitted to our institute again in December 2019. Hb decreased continuously from 115 g/l to 79 g/l in four days after admission, and showed no obvious improvement even after blood transfusions. At that point, serum PSA was 0.416 ng/mL (normal value: 0–4 ng/mL), T was 4.33 ng/dl (normal value: 193–740 ng/dl), SCr was 86 μmol/l. Although SPECT indicated no significant change in bone metastases , the pelvic enhanced MRI suggested that the primary prostate cancer tumor was enlarged with bladder invasion and the parailiac lymph nodes were involved . An emergency contrast-enhanced computed tomography (CT) of the chest and abdomen further suggested that the tumor had metastasized to thoracic vertebra without urinary obstruction and ureterohydronephrosis. To sum up, the disease has progressed to the more aggressive CRPC stage.\nIn consideration of the relative stable PSA level and the rapid progression of the disease, we tested the serum NSE with a value of 170.8 ng/mL (normal value: 0–17 ng/mL). All these results indicated a possible formation of t-NEPC. Therefore, a secondary biopsy of the enlarged primary tumor was performed. The results of pathology showed small-cell neuroendocrine carcinoma . The immunohistochemical staining contained features of t-NEPC, which had an intensive Ki67 expression (70%), was negative for PSA staining and positive for synaptophysin and CD56 ( and ). Furthermore, a genetic testing of the blood sample showed germ-line mutations of RB1 and FOXA1 , both of which are tightly associated with the formation of t-NEPC.\nThe effect of conservative treatments (eg, continuous bladder irrigation, fluid infusion and blood transfusion) for hematuria was limited. To control the bleeding of the primary tumor and relieve symptoms, the patient was treated with superselective prostate artery embolization (PAE) after multi-disciplinary consultations in January 2020. During the surgery, digital subtraction angiography (DSA) revealed extravasation of contrast medium from branches of right prostatic artery . Then, superselective PAE was performed to terminate the bleeding. Polyvinyl alcohol particles (PVA) were successfully injected into the right prostatic artery . We also found that a large amount of contrast medium overflowed at the terminal of the left prostatic artery . However, the left internal pudendal artery was selected to be embolized with infusion of PVA, gelatin sponge and spring coil due to the malformation of the left prostatic artery . Finally, the hematuria was controlled immediately with no obvious discomfort after operation.\nAfter analyzing all test results and conducting a comprehensive evaluation, we have realized that the patient was not suitable for platinum-based chemotherapy due to his weak constitution. For this reason, to further control the disease and relieve pain of the patient, palliative radiotherapy (intensity modulated radiation therapy, IMRT) to the pelvic tumor (60.2 Gy/2.15 Gy/28 fractions), the lymph drainage area (50.4 Gy/1.8Gy/28 fractions) and bone metastases (30Gy/3Gy/10 fractions) was performed in the Department of Tumor Radiotherapy of our institution in February 2020. The LUTS were relieved effectively after the palliative radiotherapy. The tumor biomarkers decreased after the superselective PAE and the radiation therapy (NSE from 170.8 ng/mL to 32 ng/mL; PSA from 0.416 ng/mL to 0.058 ng/mL). Moreover, enhanced MRI in May 2020 showed that the primary tumor was smaller than that in December 2019 . Unfortunately, the patient could not withstand the pain of the disease and then refused the follow-up treatments. He eventually died of cachexia and multiple organ failure at home on July 12, 2020.", + "fulltext_subclaims": [ + "An 80-year-old man was admitted to our institute for lower urinary tract symptoms (LUTS) in April 2018.", + "The patient's International Prostate Symptom Score (IPSS) was evaluated as 30.", + "The patient's Quality of life (QoL) was scored as 5 points.", + "The patient's Eastern Cooperative Oncology Group (ECOG) performance status was 0.", + "Digital rectal examination revealed a grade III enlarged prostate.", + "The patient's serum prostate-specific antigen (PSA) was 145.6 ng/mL.", + "The pelvic enhanced magnetic resonance imaging (MRI) showed a high possibility of prostate cancer.", + "The seminal vesicles and pelvic bones were invaded.", + "Transrectal ultrasound-guided biopsy revealed poorly differentiated AdPC after pathological examination.", + "The Gleason score was 9 (4 + 5).", + "The clinical stage was determined as stage IV (T3b N0 M1b).", + "The patient agreed to accept the ADT comprising bicalutamide (50 mg, once a day) combined with goserelin (10.8 mg, once every three months) since April 2018.", + "The patient had a good response to the aforementioned therapy with the LUTS improved (IPSS 15, QoL 3).", + "Serum PSA level decreased to 0.077 ng/mL.", + "Subsequent pelvic enhanced MRI and SPECT suggested the volume of the primary tumor and metastases was significantly reduced at the follow-up in June 2019.", + "The patient was admitted again in December 2019.", + "Hb decreased continuously from 115 g/l to 79 g/l in four days after admission.", + "Serum PSA was 0.416 ng/mL.", + "The pelvic enhanced MRI suggested that the primary prostate cancer tumor was enlarged with bladder invasion.", + "The tumor had metastasized to thoracic vertebra.", + "The disease has progressed to the more aggressive CRPC stage.", + "Serum NSE was 170.8 ng/mL.", + "A secondary biopsy of the enlarged primary tumor was performed.", + "The results of pathology showed small-cell neuroendocrine carcinoma.", + "The immunohistochemical staining contained features of t-NEPC.", + "A genetic testing of the blood sample showed germ-line mutations of RB1 and FOXA1.", + "The patient was treated with superselective prostate artery embolization (PAE) after multi-disciplinary consultations in January 2020.", + "Digital subtraction angiography (DSA) revealed extravasation of contrast medium from branches of right prostatic artery.", + "Polyvinyl alcohol particles (PVA) were successfully injected into the right prostatic artery.", + "The left internal pudendal artery was selected to be embolized with infusion of PVA, gelatin sponge and spring coil.", + "The hematuria was controlled immediately with no obvious discomfort after operation.", + "Palliative radiotherapy (intensity modulated radiation therapy, IMRT) to the pelvic tumor, the lymph drainage area and bone metastases was performed in February 2020.", + "The LUTS were relieved effectively after the palliative radiotherapy.", + "The tumor biomarkers decreased after the superselective PAE and the radiation therapy (NSE from 170.8 ng/mL to 32 ng/mL; PSA from 0.416 ng/mL to 0.058 ng/mL).", + "Enhanced MRI in May 2020 showed that the primary tumor was smaller than that in December 2019.", + "The patient eventually died of cachexia and multiple organ failure at home on July 12, 2020." + ], + "summary": "An 80-year-old man with a significantly high prostate-specific antigen was diagnosed via pathology as advanced AdPC due to multiple bone metastases. He then received ADT including bicalutamide and goserelin. After 20 months of stable disease, the cancer rapidly progressed and presented with severe gross hematuria caused by bleeding of the primary tumor. The histopathologic analysis of a secondary biopsy of the primary tumor confirmed neuroendocrine prostate cancer, and subsequent genetic testing revealed germ-line mutations in the RB1 and FOXA1. To control the bleeding and relieve symptoms, the patient was treated with superselective prostate artery embolization (PAE). After the left internal pudendal artery and the right prostatic artery were embolized, hematuria was quickly alleviated and disappeared. However, the patient was not a suitable candidate to platinum-based chemotherapy due to weak constitution. Goserelin was continuously applied to maintain castration level of serum testosterone. Meanwhile, palliative radiotherapy to the prostate tumor, high-risk lymph node drainage areas (including iliac and para-aortic lymph nodes, internal iliac lymph nodes, presacral lymph nodes and obturator nerve lymph nodes) and bone metastases (right sacroiliac joint and thoracic vertebra) was performed and relieved the pain. Unfortunately, this patient eventually died of cachexia and multiple organ failure nearly 27 months after initial diagnosis.", + "summary_subclaims": [ + "An 80-year-old man with a significantly high prostate-specific antigen was diagnosed via pathology as advanced AdPC due to multiple bone metastases.", + "He received ADT including bicalutamide and goserelin.", + "After 20 months of stable disease, the cancer rapidly progressed and presented with severe gross hematuria caused by bleeding of the primary tumor.", + "The histopathologic analysis of a secondary biopsy of the primary tumor confirmed neuroendocrine prostate cancer.", + "Subsequent genetic testing revealed germ-line mutations in the RB1 and FOXA1.", + "The patient was treated with superselective prostate artery embolization (PAE).", + "After the left internal pudendal artery and the right prostatic artery were embolized, hematuria was quickly alleviated and disappeared.", + "The patient was not a suitable candidate to platinum-based chemotherapy due to weak constitution.", + "Goserelin was continuously applied to maintain castration level of serum testosterone.", + "Palliative radiotherapy to the prostate tumor, high-risk lymph node drainage areas and bone metastases was performed.", + "The patient eventually died of cachexia and multiple organ failure nearly 27 months after initial diagnosis." + ] + }, + { + "id": "multiclinsum_test_3116_en.txt", + "fulltext": "60-year-old male with a diagnosis of post-traumatic hydrocephalus who required the implantation of a DVP. The postoperative cranial computed tomography (CT) and the postoperative radiographs of the valve path confirmed the correct placement of the proximal catheter in the ventricle and a proper path of the distal catheter to the peritoneum, with immediate postoperative clinical improvement.\n\nThirteen months later, the patient had a new clinical deterioration with gait, memory, and executive function impairments. X-rays of the valve tract were performed. The distal catheter was located in the right cavities and pulmonary artery on the chest X-ray, which was confirmed by a thoracic CT scan.\n\nThe patient underwent surgery, reopening the previous retroauricular incision to remove the catheter by hand, without incident. A new catheter was implanted at the peritoneal level with immediate clinical improvement. The patient received enoxaparin at prophylactic doses during the five-day hospital admission, without developing thromboembolism. Two years later, the patient remains clinically stable and has not had any further complications.\n", + "fulltext_subclaims": [ + "The patient is a 60-year-old male.", + "The patient had a diagnosis of post-traumatic hydrocephalus.", + "The patient required the implantation of a DVP.", + "The postoperative cranial CT confirmed the correct placement of the proximal catheter in the ventricle.", + "The postoperative radiographs of the valve path confirmed a proper path of the distal catheter to the peritoneum.", + "There was immediate postoperative clinical improvement.", + "Thirteen months later, the patient had a new clinical deterioration.", + "The clinical deterioration included gait impairments.", + "The clinical deterioration included memory impairments.", + "The clinical deterioration included executive function impairments.", + "X-rays of the valve tract were performed.", + "The distal catheter was located in the right cavities on the chest X-ray.", + "The distal catheter was located in the pulmonary artery on the chest X-ray.", + "This was confirmed by a thoracic CT scan.", + "The patient underwent surgery.", + "The previous retroauricular incision was reopened.", + "The catheter was removed by hand.", + "The removal was without incident.", + "A new catheter was implanted at the peritoneal level.", + "There was immediate clinical improvement.", + "The patient received enoxaparin at prophylactic doses.", + "The enoxaparin was administered during the five-day hospital admission.", + "The patient did not develop thromboembolism.", + "Two years later, the patient remains clinically stable.", + "The patient has not had any further complications." + ], + "summary": "A 60-year-old male with posttraumatic hydrocephalus underwent a ventriculo-peritoneal shunt. After initial clinical improvement, thirteen months later he developed gait deterioration and cognitive problems. Chest X-ray and computed tomography showed that the distal catheter of the shunt had migrated to the pulmonary artery. The catheter was removed surgically by reopening the pre-existing retroauricular incision and manual traction, without incident. A new peritoneal catheter was implanted with immediate clinical improvement. Two years later, the patient remains asymptomatic.\n", + "summary_subclaims": [ + "The patient is a 60-year-old male.", + "The patient had posttraumatic hydrocephalus.", + "The patient underwent a ventriculo-peritoneal shunt.", + "The patient had initial clinical improvement.", + "Thirteen months later, the patient developed gait deterioration.", + "Thirteen months later, the patient developed cognitive problems.", + "Chest X-ray showed that the distal catheter of the shunt had migrated to the pulmonary artery.", + "Computed tomography showed that the distal catheter of the shunt had migrated to the pulmonary artery.", + "The catheter was removed surgically by reopening the pre-existing retroauricular incision.", + "The catheter was removed by manual traction.", + "The removal was without incident.", + "A new peritoneal catheter was implanted.", + "There was immediate clinical improvement.", + "Two years later, the patient remains asymptomatic." + ] + }, + { + "id": "multiclinsum_test_2037_en.txt", + "fulltext": "A 12-year-old boy was admitted to our hospital on September 10, 2018 with a chief complaint of calvarial mass for 2 mo and multiple masses around the whole body for more than 1 mo.\nAt 2 mo before hospital admission, a mass with a diameter of 2 cm on the left parietal was found in the patient, without local swelling, heat, or pain. The mass was considered a “scalp cyst” by the local hospital and was surgically resected without a pathological diagnosis. The masses resurfaced on the scalp on day 7 after surgery and quickly involved the whole body within 4 wk. The masses were hard and in progressive enlargement. The patient suffered fever, low back pain, sensory and motor dysfunction in the lower limbs, left eyeball protrusion, poor appetite and weight loss of 4 kg (13.3%). Ceftizoxime (1.3 g, intravenous infusion every 12 h [Q12H]) for anti-infection and mannitol (100 mL, intravenous infusion Q8H) for decreasing intracranial pressure were not effective.\nAccording to the past medical history, the patient was in good health.\nHe had no family history of hematological diseases or tumors.\nPhysical examination on admission was as follows: clear mind, weak reaction, appearance of malnutrition, painful expression, and passive position. The superficial lymph nodes around the whole body appeared a multiple, enlarged, and qualitative hard, with a diameter of 1.5-5 cm. Multiple subcutaneous nodules and masses were observed throughout the body, with sizes of 1-3 cm in diameter and tough/hard in texture. The left maxillofacial area was swollen with exophthalmos of the left eyeball. Cardiopulmonary and abdominal examinations showed no abnormalities. Muscle tension in both lower limbs was reduced with a muscle strength grade of 0. Abdominal reflexes and cremasteric reflexes still exist, but bilateral patellar tendon and Achilles tendon reflex are absent. Tests results were positive for Kernig sign, bilateral Babinski sign and Chaddock sign; and negative for Brudzinski’s sign.\nThere were normal peripheral white blood cell counts and hemoglobin levels, elevated platelet 822 × 109/L (normal reference range 100-300 × 109/L), significantly elevated lactic dehydrogenase 1345 U/L (normal reference range 110-295 U/L), normal blood coagulation, and test results for hepatitis B, hepatitis C, hepatitis E, Epstein-Barr virus, cytomegalovirus, human immunodeficiency virus were negative. The cerebrospinal fluid was pale yellow and transparent with normal white blood cells, glucose, chloride, and protein levels, and no tumor cells were found. Bone marrow smears indicated 7%-47.5% of tumor cells, with large cell bodies, large amount of gray-blue cytoplasm, and fine nuclear chromatin . Flow cytometry analysis of bone marrow demonstrated that 4.48% of the cells expressed CD4dim but not CD45, CD56, CD8, CD3, CD2, CD7, CD30, cCK, GD2, CD15, cCD3, CD20, cCD79, Ki67, and so on, malignant hematopoietic system cells should be considered.\nPositron emission tomography/computed tomography revealed multiple enlarged lymph nodes in the neck, mediastinum, abdomen, pelvis, and inguinal region; and nodular lesions with increased level of 18-fluorodeoxyglucose metabolism in the encephalon, left posterior pharyngeal wall, left external rectus muscle, left lateral femur muscles and left kidney .\nBone marrow biopsy revealed the absence of hematopoietic cells, infiltration of diffuse tumor cells, large volume of tumor cells, few lightly stained cytoplasm, some of which were vacuolar, presenting immunoblast-like appearance; round or irregular cell nuclei, light staining, prominent nucleoli; mononuclear and multinuclear tumor cells. Immunohistochemistry performed using lymphohematopoietic system markers indicated as follows: positive for CD45, weakly positive for CD10 and CD163; T-cell markers: negative for CD3 and CD5; B-cell markers: negative for CD20, CD79a, and paired box 5 (PAX5); immature cell markers: negative for CD34, CD117, TDT, CD123 and CD43; other markers: negative for CD56 and CD30. Lymphohematopoietic tumor should be considered, if it was unable to classify, myeloid sarcoma should be considered.\nTo obtain a definite diagnosis, a neck lymph node biopsy was performed. Microscopic analysis showed the structure of the lymph node was destroyed, and it consisted of single large immunoblast-like cells, with round and light nuclei, large nucleoli and abundant cytoplasm; plasmoblast differentiation appeared; atypical multinucleated tumor giant cells were observed occasionally; presented as intrasinusoidal growth patterns. Immunohistochemistry analysis indicated as follows: T/natural killer cell markers: negative for CD2, CD3, CD43, CD4, CD8, TIA-1, and CD56; B/plasmocyte markers: positive for OCT2, BOB1, CD38 (focal weak), and MUM1; and negative for CD20, CD79a, PAX5, CD138; other immunomarkers: positive for LCA (leukocyte common antigen), ALK (cytoplasm, granular), immunoglobulin A, Ki-67 (> 90%), EMA, CD31, and FLI-1 ; negative for CD30, CD163, S-100, CD34, and TDT.\nFluorescence in situ hybridization (FISH) study with ALK break apart probe (Wuhan HealthCare Biotechnology Co., Ltd., Wuhan, China) showed ALK gene disruption in the cervical lymph node. B-cell clonality assays revealed monoclonal IGH rearrangement. Next-generation sequencing (NGS) high-throughput RNA sequencing was performed for genetic testing of tumor cells in bone marrow, and in combination with Sanger first-generation sequencing, the CLTC-ALK fusion gene in the bone marrow of the patient was observed positive , in addition to the PGS1-CLTC fusion gene.", + "fulltext_subclaims": [ + "The patient was a 12-year-old boy.", + "He was admitted on September 10, 2018.", + "The chief complaint was a calvarial mass for 2 mo and multiple masses around the whole body for more than 1 mo.", + "A mass with a diameter of 2 cm on the left parietal was found 2 mo before hospital admission.", + "The mass was considered a 'scalp cyst' by the local hospital.", + "The mass was surgically resected without a pathological diagnosis.", + "The masses resurfaced on the scalp on day 7 after surgery.", + "The masses quickly involved the whole body within 4 wk.", + "The masses were hard and in progressive enlargement.", + "The patient suffered fever.", + "The patient had low back pain.", + "The patient had sensory and motor dysfunction in the lower limbs.", + "The patient had left eyeball protrusion.", + "The patient had poor appetite and weight loss of 4 kg (13.3%).", + "Ceftizoxime (1.3 g, intravenous infusion every 12 h) was administered.", + "Mannitol (100 mL, intravenous infusion Q8H) was administered.", + "Ceftizoxime and mannitol were not effective.", + "The patient had no family history of hematological diseases or tumors.", + "Physical examination showed multiple, enlarged, hard superficial lymph nodes with a diameter of 1.5-5 cm.", + "Multiple subcutaneous nodules and masses were observed throughout the body, with sizes of 1-3 cm in diameter.", + "The left maxillofacial area was swollen with exophthalmos of the left eyeball.", + "Muscle tension in both lower limbs was reduced with a muscle strength grade of 0.", + "Tests results were positive for Kernig sign, bilateral Babinski sign, and Chaddock sign.", + "Tests results were negative for Brudzinski’s sign.", + "Platelet count was 822 × 109/L.", + "Lactic dehydrogenase was 1345 U/L.", + "Bone marrow smears indicated 7%-47.5% of tumor cells.", + "Flow cytometry analysis of bone marrow demonstrated 4.48% of the cells expressed CD4dim but not CD45, CD56, CD8, CD3, CD2, CD7, CD30, cCK, GD2, CD15, cCD3, CD20, cCD79, Ki67, and so on.", + "Positron emission tomography/computed tomography revealed multiple enlarged lymph nodes in the neck, mediastinum, abdomen, pelvis, and inguinal region.", + "Bone marrow biopsy revealed the absence of hematopoietic cells and infiltration of diffuse tumor cells.", + "Immunohistochemistry performed using lymphohematopoietic system markers indicated positive for CD45, weakly positive for CD10 and CD163.", + "T-cell markers were negative for CD3 and CD5.", + "B-cell markers were negative for CD20, CD79a, and PAX5.", + "Immature cell markers were negative for CD34, CD117, TDT, CD123, and CD43.", + "Other markers were negative for CD56 and CD30.", + "A neck lymph node biopsy was performed.", + "Microscopic analysis showed the structure of the lymph node was destroyed.", + "Immunohistochemistry analysis indicated positive for OCT2, BOB1, CD38 (focal weak), and MUM1.", + "Fluorescence in situ hybridization study with ALK break apart probe showed ALK gene disruption in the cervical lymph node.", + "B-cell clonality assays revealed monoclonal IGH rearrangement.", + "Next-generation sequencing high-throughput RNA sequencing was performed for genetic testing of tumor cells in bone marrow.", + "The CLTC-ALK fusion gene in the bone marrow of the patient was observed positive." + ], + "summary": "We present a case of a 12-year-old boy diagnosed with ALK+LBCL. The patient had a 2-mo medical history of a calvarial mass, extensive systemic involvement, and positive bone marrow clathrin heavy chain (CLTC)-ALK fusion gene. Complete remission 1 (CR1) was achieved using the modified LMB89 Group C regimen followed by autologous stem cell transplantation. The patient relapsed 3 mo later. He then achieved CR2 with three short courses of chemotherapy (COP, reduced-dose ICE, low-dose Ara-c+VP16) and continuous alectinib targeted therapy. Afterward, allogeneic hematopoietic stem cell transplantation (allo-HSCT) was performed. At 16 mo after the allo-HSCT, the patient was still in CR2.", + "summary_subclaims": [ + "The patient was a 12-year-old boy.", + "The patient was diagnosed with ALK+LBCL.", + "The patient had a 2-mo medical history of a calvarial mass.", + "The patient had extensive systemic involvement.", + "The bone marrow clathrin heavy chain (CLTC)-ALK fusion gene was positive.", + "Complete remission 1 (CR1) was achieved using the modified LMB89 Group C regimen.", + "Autologous stem cell transplantation was performed.", + "The patient relapsed 3 mo later.", + "CR2 was achieved with three short courses of chemotherapy.", + "The chemotherapy regimens included COP, reduced-dose ICE, and low-dose Ara-c+VP16.", + "Continuous alectinib targeted therapy was used.", + "Allogeneic hematopoietic stem cell transplantation (allo-HSCT) was performed.", + "At 16 mo after the allo-HSCT, the patient was still in CR2." + ] + }, + { + "id": "multiclinsum_test_1925_en.txt", + "fulltext": "A 43-year-old man presented with a 2-month history of side-locked attacks of excruciatingly severe stabbing and boring left-sided pain located in the orbit. The attacks were associated with nasal obstruction, conjunctival injection, and restlessness and migrainous features such as nausea and photophobia/phonophobia. No continuous background pain was identified. The duration of the attacks was about 30 min and the frequency 4 to 5 per 24 h, 3 to 4 days a week and they also occurred during the night. There was no history of headache. His medical and family history was otherwise unremarkable. He was not on any medications and used no drugs. Vital signs, physical examination, and neurological examination were normal. Laboratory testing was normal. He satisfied the revised International Classification of Headache Disorders criteria for CH. A diagnosis of CH was made and subcutaneous sumatriptan as well as oral sumatriptan were prescribed. A prophylactic treatment with steroids and verapamil was suggested but the patient preferred symptomatic medication instead of using a prophylactic drug for CH. He responded to the treatment with relief within 15 to 20 min. A follow-up was planned. As the headache attacks continued, the patient was hospitalized after about 1 month. At admission, the neurological examination was normal. He was on the following medication: subcutaneous/oral sumatriptan when required. A CT scan of the head displayed a supra- and intrasellar arachnoid cyst with mass effect . An enhanced magnetic resonance imaging (MRI) was ordered in order to further evaluate the lesion. It confirmed the diagnosis of a supra- and intrasellar arachnoid cyst with mass effect on adjacent structures . Operation (craniotomy with cyst fenestration) and histopathological examination verified the diagnosis of AC. The headache attacks resolved completely after the surgery. He remained headache free and had not experienced any headache attacks at follow-up after 4 months.", + "fulltext_subclaims": [ + "The patient is a 43-year-old man.", + "He had a 2-month history of side-locked attacks of excruciatingly severe stabbing and boring left-sided pain located in the orbit.", + "The attacks were associated with nasal obstruction.", + "The attacks were associated with conjunctival injection.", + "The attacks were associated with restlessness.", + "The attacks were associated with migrainous features such as nausea and photophobia/phonophobia.", + "No continuous background pain was identified.", + "The duration of the attacks was about 30 min.", + "The frequency of the attacks was 4 to 5 per 24 h.", + "The attacks occurred 3 to 4 days a week.", + "The attacks also occurred during the night.", + "There was no history of headache.", + "His medical and family history was otherwise unremarkable.", + "He was not on any medications.", + "He used no drugs.", + "Vital signs were normal.", + "Physical examination was normal.", + "Neurological examination was normal.", + "Laboratory testing was normal.", + "He satisfied the revised International Classification of Headache Disorders criteria for CH.", + "A diagnosis of CH was made.", + "Subcutaneous sumatriptan was prescribed.", + "Oral sumatriptan was prescribed.", + "A prophylactic treatment with steroids and verapamil was suggested.", + "The patient preferred symptomatic medication instead of using a prophylactic drug for CH.", + "He responded to the treatment with relief within 15 to 20 min.", + "A follow-up was planned.", + "The patient was hospitalized after about 1 month.", + "At admission, the neurological examination was normal.", + "He was on subcutaneous/oral sumatriptan when required.", + "A CT scan of the head displayed a supra- and intrasellar arachnoid cyst with mass effect.", + "An enhanced magnetic resonance imaging (MRI) was ordered in order to further evaluate the lesion.", + "The MRI confirmed the diagnosis of a supra- and intrasellar arachnoid cyst with mass effect on adjacent structures.", + "Operation (craniotomy with cyst fenestration) and histopathological examination verified the diagnosis of AC.", + "The headache attacks resolved completely after the surgery.", + "He remained headache free and had not experienced any headache attacks at follow-up after 4 months." + ], + "summary": "We present a case of a 43-year-old patient who presented with a 2-month history of side-locked attacks of pain located in the left orbit. He satisfied the revised International Classification of Headache Disorders criteria for cluster headache. His medical and family histories were unremarkable. There was no history of headache. A diagnosis of cluster headache was made. The patient responded to symptomatic treatment. Computer tomography and enhanced magnetic resonance imaging after 1 month displayed a supra- and intrasellar arachnoid cyst with mass effect on adjacent structures. After operation, the headache attacks resolved completely.", + "summary_subclaims": [ + "The patient was a 43-year-old individual.", + "The patient had a 2-month history of side-locked attacks of pain located in the left orbit.", + "The patient satisfied the revised International Classification of Headache Disorders criteria for cluster headache.", + "The patient's medical and family histories were unremarkable.", + "There was no history of headache.", + "A diagnosis of cluster headache was made.", + "The patient responded to symptomatic treatment.", + "Computer tomography and enhanced magnetic resonance imaging after 1 month displayed a supra- and intrasellar arachnoid cyst with mass effect on adjacent structures.", + "After operation, the headache attacks resolved completely." + ] + }, + { + "id": "multiclinsum_test_1935_en.txt", + "fulltext": "A 55-year-old man, with severe left main coronary artery disease (CAD), and with short stature (150 cm height) and 76 kg weight, was referred to our center for coronary artery bypass grafting (CABG). The patient scheduled for off-pump CABG (OPCAB).\nDue to unstable hemodynamic condition, an IABP catheter (Datascope, procure, state, dual lumen, 9.5F, 34 ml, Datascope Inc., Montreal, NJ, United States) was inserted percutaneously through the right femoral artery, and was attached to the Datascope system via a console. Immediately after device insertion, with a counter pulsation and 100% augmentation, and a ratio of 1:1, the systolic blood pressure increased up to 90 mmHg, and urine output increased.\nThe patient underwent an OPCAB operation using conventional grafts such as the left internal thoracic artery and saphenous vein grafts. Following the extubation, urine output was decreased that managed by diuretic and fluid therapy. Although, laboratory examination showed abrupt increasing of the following test: blood urea nitrogen (BUN): 70 mg/dl, creatinine (CR): 1.6 mg/dl, aspartate transaminase (AST): 80 IU, alanine aminotransferase (ALT): 70 IU, and acetate dehydrogenase (LDH): 350 IU. AST, ALT, and LDH values elevated seriously to 1200, 3500, and 5500 IU, respectively. The BUN and creatinine also increased to 80 and 2.1 mg/dl, respectively. The mean elevation of total bilirubin was also noted (total bilirubin: 2.5 mg/dl).\nThe distension caused the failure of Doppler to reveal the condition of portal and liver venous and arterial flow blood flow, but showed the reduction of renal arterial blood flow. However, in a thoracic X-ray catheter’s tip was not detected, and an abdominal X-Ray showed that the balloon pump catheter’s tip was displaced distally; uncovering of catheter dressing in right thigh revealed loosing of fixation suture of catheter to the skin in its correct position .\nThe improper mismatching of the IABP catheter size with the patient length may be another possible cause of the liver, renal, and mesenteric arterial malperfusion in this specific case. After IABP removal, the patient urine output was abruptly increased on the following hours. Then, the liver function tests, including ALT, AST, LDH, total bilirubin, and prothrombin time continued to reduce, and recovered drastically at the 10th day of catheter removal; liver function tests returned to normal value at time of hospital discharge, too.", + "fulltext_subclaims": [ + "The patient is a 55-year-old man.", + "The patient has severe left main coronary artery disease.", + "The patient is 150 cm tall.", + "The patient weighs 76 kg.", + "The patient was referred for coronary artery bypass grafting.", + "The patient was scheduled for off-pump CABG.", + "An IABP catheter was inserted percutaneously through the right femoral artery.", + "The IABP catheter was a Datascope, procure, state, dual lumen, 9.5F, 34 ml catheter.", + "The IABP catheter was attached to the Datascope system via a console.", + "Counterpulsation was set to 100% augmentation.", + "The counterpulsation ratio was 1:1.", + "Systolic blood pressure increased to 90 mmHg after device insertion.", + "Urine output increased immediately after device insertion.", + "The patient underwent OPCAB using conventional grafts.", + "The grafts included the left internal thoracic artery and saphenous vein grafts.", + "Following extubation, urine output was decreased.", + "Diuretic and fluid therapy were used to manage decreased urine output.", + "Blood urea nitrogen increased to 70 mg/dl.", + "Creatinine increased to 1.6 mg/dl.", + "AST increased to 80 IU.", + "ALT increased to 70 IU.", + "LDH increased to 350 IU.", + "AST, ALT, and LDH values elevated to 1200, 3500, and 5500 IU, respectively.", + "BUN increased to 80 mg/dl.", + "Creatinine increased to 2.1 mg/dl.", + "Total bilirubin increased to 2.5 mg/dl.", + "Doppler failed to reveal portal and liver venous and arterial blood flow.", + "Renal arterial blood flow was reduced.", + "The IABP catheter’s tip was not detected in a thoracic X-ray.", + "An abdominal X-ray showed the IABP catheter’s tip was displaced distally.", + "The IABP catheter’s fixation suture to the skin was loose.", + "Improper mismatching of the IABP catheter size with the patient’s length may be a possible cause of malperfusion.", + "After IABP removal, urine output abruptly increased.", + "Liver function tests continued to reduce after IABP removal.", + "Liver function tests recovered drastically at the 10th day of catheter removal.", + "Liver function tests returned to normal at the time of hospital discharge." + ], + "summary": "A 55-year-old man with severe left ventricular dysfunction underwent coronary artery bypass grafting (CABG) with the preoperative use of an intra-aortic balloon pump. Postoperative course was complicated by renal and hepatic failure. The early occurrence of complications during 36 hours after operation exhibited a serious vascular complication. The combination of acute renal and hepatic failure led to the suspension to occlusive effect of intra-aortic balloon pump catheter on ostium of the aforementioned organs. The intra-aortic balloon pump was removed, and urine output immediately restored. Thereafter, daily slop dawn serum levels of aminotransferases were started, and became normal at the 10th day of operation.", + "summary_subclaims": [ + "The patient is a 55-year-old man.", + "The patient had severe left ventricular dysfunction.", + "The patient underwent coronary artery bypass grafting.", + "An intra-aortic balloon pump was used preoperatively.", + "The postoperative course was complicated by renal and hepatic failure.", + "A serious vascular complication occurred within 36 hours after operation.", + "The intra-aortic balloon pump catheter's occlusive effect on the ostium of the aforementioned organs was suspended.", + "The intra-aortic balloon pump was removed.", + "Urine output immediately restored after removal of the intra-aortic balloon pump.", + "Daily slop dawn serum levels of aminotransferases were started.", + "Aminotransferase levels became normal at the 10th day of operation." + ] + }, + { + "id": "multiclinsum_test_1744_en.txt", + "fulltext": "The patient was a 38-year-old non-smoking Japanese woman with no significant medical history. She was diagnosed with invasive ductal carcinoma of the right breast, and in August 2020, we performed partial right breast resection and axillary lymph node dissection. Her post-operative diagnosis was pT2N2aM0 pStage IIB, ER(+) PgR(+) HER2(−), and she was administered her first course of chemotherapy with (5-Fluorouracil 500 mg/m2), epirubicin hydrochloride (100 mg/m2), and cyclophosphamide (500 mg/m2) (FEC) every 3 weeks in mid-September.\nA day before receiving the second course of chemotherapy, she had a fever of 38.0 °C. The next morning, her fever had alleviated, and she visited our outpatient department. She had no cough at this point. Her blood test showed no abnormalities; therefore, we administered a second course of chemotherapy. As an antiemetic agent, she received 8 mg/day of dexamethasone on days 1–4 and an aprepitant on days 1–3. According to our hospital’s standardized treatment, on day 3, she received a shot of peg-filgrastim (3.6 mg).\nOn days 5 and 6 after the administration of chemotherapy, she had a fever ranging from 39–40 °C. On day 7, she tested positive for SARS-CoV-2 by reverse transcription polymerase chain reaction (RT-PCR).\nThe next day, she was admitted to our hospital for treatment. Her main symptoms were cough and high temperature. Additional symptoms included fatigue and mild joint pain. She did not show any signs of hypoxemia. Laboratory tests revealed the following findings: white blood cell count, 1600/μL with 77.0% neutrophils, 17.0% lymphocytes, 3.0% monocytes, 1.0% eosinophils, 2.0% basophils; hemoglobin, 12.6 g/dL; platelet count, 140,000/μL; and C-reactive protein 3.62 mg/dL. Chest computed tomography (CT) revealed ground-glass opacity in the peripheral lesions of both lungs . Chest X-ray indicated infiltrative shadows in the peripheral lesions of both lungs . She was diagnosed with COVID-19 with grade three leukopenia and grade two neutropenia. Antibiotic therapy (levofloxacin 500 mg every 24 h, taken orally) was administered after collecting blood cultures.\nAntibiotic therapy was discontinued after a blood test showed normalization of her white blood cell count on day 5 after the diagnosis. Intermittent cough and high temperature persisted until day 8 after the diagnosis. After confirming that at least 72 h had passed, since her last episode of fever, she was discharged 12 days after the diagnosis (day 19 after the administration of chemotherapy Fig. ).\nThe patient visited our outpatient department 2 weeks after discharge for a chest X-ray and blood test follow-up. The blood test indicated the normalization of inflammatory markers, and the chest X-ray images showed benign organized pneumonia in the peripheral lesion of both lungs, matching the ground-glass opacities seen in the CT before .\nIn considering resumption of chemotherapy, we consulted a pulmonologist. Since no criteria exist, we were advised based on clinical experience, to defer resumption until at least 2 weeks had passed after discharge. Taking this into account, we decided to resume anti-cancer therapy after adequately informing the patient about the risks and benefits. FEC therapy every 3 weeks was resumed on day 25 after discharge (day 43 after the last administration of the chemotherapy). The patient was able to complete four courses of the initial chemotherapy without any major adverse events, and we were able to institute docetaxel (70 mg/m2) every 3 weeks as the second regimen of chemotherapy. Organized pneumonia was eclipsed in the follow-up chest X-ray image taken at the beginning of docetaxel therapy . She completed four courses of docetaxel without any major adverse events.", + "fulltext_subclaims": [ + "The patient was a 38-year-old non-smoking Japanese woman.", + "She had no significant medical history.", + "She was diagnosed with invasive ductal carcinoma of the right breast.", + "In August 2020, she underwent partial right breast resection and axillary lymph node dissection.", + "Her post-operative diagnosis was pT2N2aM0 pStage IIB.", + "Her tumor was ER(+) PgR(+) HER2(−).", + "She received her first course of chemotherapy with FEC in mid-September.", + "The FEC regimen included 5-Fluorouracil 500 mg/m2, epirubicin hydrochloride 100 mg/m2, and cyclophosphamide 500 mg/m2.", + "The chemotherapy was administered every 3 weeks.", + "A day before the second course of chemotherapy, she had a fever of 38.0 °C.", + "The fever had alleviated by the next morning.", + "She had no cough at that time.", + "Blood tests showed no abnormalities.", + "She received a second course of chemotherapy.", + "She received 8 mg/day of dexamethasone on days 1–4 as an antiemetic.", + "She received aprepitant on days 1–3.", + "She received a shot of peg-filgrastim (3.6 mg) on day 3.", + "On days 5 and 6 after chemotherapy, she had a fever ranging from 39–40 °C.", + "On day 7, she tested positive for SARS-CoV-2 by RT-PCR.", + "She was admitted to the hospital the next day.", + "Her main symptoms were cough and high temperature.", + "Additional symptoms included fatigue and mild joint pain.", + "She did not show signs of hypoxemia.", + "Her white blood cell count was 1600/μL.", + "Her neutrophil percentage was 77.0%.", + "Her lymphocyte percentage was 17.0%.", + "Her platelet count was 140,000/μL.", + "Chest CT showed ground-glass opacity in the peripheral lesions of both lungs.", + "Chest X-ray showed infiltrative shadows in the peripheral lesions of both lungs.", + "She was diagnosed with COVID-19.", + "She had grade three leukopenia.", + "She had grade two neutropenia.", + "Antibiotic therapy with levofloxacin 500 mg every 24 h was administered.", + "Antibiotic therapy was discontinued after normalization of white blood cell count on day 5 after diagnosis.", + "Intermittent cough and high temperature persisted until day 8 after diagnosis.", + "She was discharged 12 days after diagnosis.", + "She visited the outpatient department 2 weeks after discharge.", + "The blood test showed normalization of inflammatory markers.", + "The chest X-ray showed benign organized pneumonia in the peripheral lesion of both lungs.", + "The chest X-ray findings matched the ground-glass opacities seen in the CT before.", + "A pulmonologist was consulted regarding resumption of chemotherapy.", + "No criteria existed for resumption, so the decision was based on clinical experience.", + "Resumption was deferred until at least 2 weeks after discharge.", + "FEC therapy was resumed on day 25 after discharge.", + "The patient completed four courses of the initial chemotherapy.", + "Docetaxel (70 mg/m2) every 3 weeks was instituted as the second regimen.", + "Organized pneumonia was eclipsed in the follow-up chest X-ray at the beginning of docetaxel therapy.", + "She completed four courses of docetaxel without major adverse events." + ], + "summary": "The patient was a 38-year-old non-smoking Japanese woman with no significant medical history. She had fever on days 5 and 6 of her second course of adjuvant FEC therapy, and on day 7, she tested positive for SARS-CoV-2 by RT-PCR. She was hospitalized for 11 days. We resumed the therapy on day 25 after discharge, as she had no remaining clinical symptoms. The patient completed four courses of the initial chemotherapy without any major adverse events nor the recurrence of COVID-19, and subsequently completed four courses of docetaxel as her second regimen therapy.", + "summary_subclaims": [ + "The patient was a 38-year-old non-smoking Japanese woman.", + "She had no significant medical history.", + "She had fever on days 5 and 6 of her second course of adjuvant FEC therapy.", + "On day 7, she tested positive for SARS-CoV-2 by RT-PCR.", + "She was hospitalized for 11 days.", + "We resumed the therapy on day 25 after discharge.", + "She had no remaining clinical symptoms.", + "The patient completed four courses of the initial chemotherapy.", + "She had no major adverse events.", + "She had no recurrence of COVID-19.", + "She completed four courses of docetaxel as her second regimen therapy." + ] + }, + { + "id": "multiclinsum_test_1985_en.txt", + "fulltext": "The proband (II.1), a 22-year-old male, was the eldest son of three children born to 1st degree consanguineous parents of Sri Lankan origin . Pregnancy and delivery were uneventful. He was diagnosed to have bilateral postaxial oligodactyly limited to upper limbs at birth. Radiological studies showed bilateral fusion of the 4th and 5th metacarpal bones . He has no noticeable facial dysmorphism, renal impairments or cognitive impairments. The second child (II.2), a 16-year-old boy, was normal. The youngest child (II.3), a 13-year-old girl, also has postaxial oligodactyly and a few mild facial dysmorphic features. Both patients do not show visible lower limb deformities or oligodactyly. By whole exome sequencing of the proband, we identified a deleterious homozygous mutation in LRP4 c.1348A > G, p.Ile450Val. Mutations in this gene were reported to cause CLS syndrome.", + "fulltext_subclaims": [ + "The proband (II.1) is a 22-year-old male.", + "The proband is the eldest son of three children born to 1st degree consanguineous parents of Sri Lankan origin.", + "Pregnancy and delivery were uneventful.", + "The proband was diagnosed to have bilateral postaxial oligodactyly limited to upper limbs at birth.", + "Radiological studies showed bilateral fusion of the 4th and 5th metacarpal bones.", + "The proband has no noticeable facial dysmorphism.", + "The proband has no renal impairments.", + "The proband has no cognitive impairments.", + "The second child (II.2) is a 16-year-old boy.", + "The second child is normal.", + "The youngest child (II.3) is a 13-year-old girl.", + "The youngest child also has postaxial oligodactyly.", + "The youngest child has a few mild facial dysmorphic features.", + "Both patients do not show visible lower limb deformities or oligodactyly.", + "Whole exome sequencing of the proband identified a deleterious homozygous mutation in LRP4 c.1348A > G, p.Ile450Val.", + "Mutations in this gene were reported to cause CLS syndrome." + ], + "summary": "we report here two patients, born to consanguineous Sri Lankan parents, present with bilateral postaxial oligodactyly limited to upper limbs. While the proband has no noticeable facial dysmorphism, renal impairments or cognitive impairments, his affected sister displays a few mild facial dysmorphic features. Whole exome sequencing of the proband showed a novel deleterious homozygous mutation (c.1348A > G) in the LRP4 gene, resulting in an Ile450-to-Val (I450V) substitution.", + "summary_subclaims": [ + "The two patients were born to consanguineous Sri Lankan parents.", + "The patients present with bilateral postaxial oligodactyly limited to upper limbs.", + "The proband has no noticeable facial dysmorphism.", + "The proband has no renal impairments.", + "The proband has no cognitive impairments.", + "The affected sister displays a few mild facial dysmorphic features.", + "Whole exome sequencing of the proband showed a novel deleterious homozygous mutation (c.1348A > G) in the LRP4 gene.", + "The mutation results in an Ile450-to-Val (I450V) substitution." + ] + }, + { + "id": "multiclinsum_test_1913_en.txt", + "fulltext": "The donor was a 35-year-old male, Maastricht category III, who died after cardiac arrest (DCD) due to intracranial haemorrhage secondary to trauma. The right kidney was sent to another centre first and declined due to vascular damage. It then went through the fast-track scheme and was accepted by our team at Guy's Hospital. Once we had the kidney, the initial evaluation showed a right kidney, with three veins in a single cava patch, three renal arteries, the main artery with aorta patch that is 8 cm long, a small lower pole artery, which was sectioned during retrieval surgery at approximately 1 cm from its origin, and a third small mid-lower pole artery. The ureter had bifid renal pelvis.\nDuring bench surgery the kidney was well perfused well with Soltran solution. From the three veins in the single cava patch, it was decided to ligate the posterior branch in order to allow the single patch to be more mobile. The small mid-lower pole artery was already damaged and was deemed unreconstructable and was therefore tied off. The main artery was left with a 1 cm aortic patch. The lower pole damaged artery was reconstructed using tubularised aorta patch to a total length of 5 cm. No additional donor vessels had been sent.\nAlthough the inferior epigastric artery is sometimes preferred for this kind of reconstruction, in this case, it would probably have been too small for the reconstruction; also, the availability of a long and healthy aortic patch and the fact that during benching we did not know the status of the recipient vessels made us decide to take this approach.\nThe reconstruction was carried out with an aorta patch that is 5 cm in length that was part of the main artery patch of the organ. Using an 8 ch Nelaton bladder catheter as a mold a 5 cm long aorta segment was tubularised using 3 7-0 Prolene interrupted stiches in the distal area to avoid stenosis and Prolene 7-0 continuous suture in the rest of the patch to minimize bleeding risk. After construction of the tubulised aorta, E-E anastomosis to the damaged polar artery was done with interrupted 7-0 Prolene .\nThe recipient was 68-year-old male, with past medical history of ESRD secondary to IgA nephropathy on peritoneal dialysis and no other medical issues nor surgical procedures. After a detailed discussion with the patient, regarding the benefits and the risks due to the surgery and donors/organ characteristics, the patient was happy to proceed and signed the consent.\nTransplant surgery was performed in the right iliac fossa with an extraperitoneal approach to the iliac vessels. The common cava patch was anastomosed to the recipient's external iliac vein. The main artery was anastomosed to the common iliac artery. Finally the reconstructed artery with the tubulised patch anastomosed the external iliac artery. After completion of all three vascular anastomoses the kidney was reperfused . The ureter was anastomosed to the bladder over a double J stent. A Robinson drain was left and wound was closed. The cold ischemic time was 27 hours and 15 minutes and warm ischemic time was 75 min.\nThere were no immediate postoperative complications. The first ultrasound was performed two hours after finishing the surgery in the recovery ward, showing good perfusion of the kidney.\nAfter 48 hours a second ultrasound was performed. The presence of a superficial haematoma within the subcutaneous tissues and slightly reduced perfusion within the interpolar region was reported; otherwise appearance of the transplant kidney was satisfactory.\nHaemoglobin fell from 11.2 (preoperatively) to 6.4 gr/dl. A decision to transfuse two units of blood cells and a relook surgery was reached. There was subcutaneous and perigraft haematoma and no active bleeding. The three vascular anastomoses were identified, both arteries, main and reconstructed, had good thrill, and the vein was soft and had good outflow. A new drain was left at the surgical site and wound closure was performed.\nThree days later, the ultrasound was repeated showing that the right iliac fossa transplant kidney had normal cortical thickness and appearance. There was no pelvicalyceal dilatation. The previously demonstrated superficial collection was no longer present. There was satisfactory global vascularity. The sampled interlobular and arcuate vessels demonstrate normal flow with resistive indices between 0.65 and 0.8. The two renal arteries and veins had normal spectral waveforms, with a final impression of normal appearances of right iliac fossa transplant kidney.\nUreteric stent was removed at week 4 after transplant. Three months after transplantation the patient was stable and had no dialysis requirements with creatinine of 187.", + "fulltext_subclaims": [ + "The donor was a 35-year-old male.", + "The donor was Maastricht category III.", + "The donor died after cardiac arrest.", + "The donor's death was due to intracranial haemorrhage secondary to trauma.", + "The right kidney was sent to another centre first.", + "The right kidney was declined due to vascular damage.", + "The right kidney then went through the fast-track scheme.", + "The right kidney was accepted by our team at Guy's Hospital.", + "The initial evaluation showed a right kidney.", + "The kidney had three veins in a single cava patch.", + "The kidney had three renal arteries.", + "The main artery had an aorta patch that is 8 cm long.", + "The lower pole artery was sectioned during retrieval surgery.", + "The sectioning occurred at approximately 1 cm from its origin.", + "The ureter had a bifid renal pelvis.", + "The kidney was well perfused with Soltran solution during bench surgery.", + "It was decided to ligate the posterior branch of the three veins in the single cava patch.", + "The small mid-lower pole artery was already damaged.", + "The small mid-lower pole artery was deemed unreconstructable.", + "The small mid-lower pole artery was therefore tied off.", + "The main artery was left with a 1 cm aortic patch.", + "The lower pole damaged artery was reconstructed using tubularised aorta patch.", + "The reconstruction resulted in a total length of 5 cm.", + "No additional donor vessels had been sent.", + "The inferior epigastric artery is sometimes preferred for this kind of reconstruction.", + "In this case, the inferior epigastric artery would probably have been too small.", + "The availability of a long and healthy aortic patch influenced the decision.", + "The status of the recipient vessels was unknown during benching.", + "The reconstruction was carried out with an aorta patch that is 5 cm in length.", + "The aorta patch was part of the main artery patch of the organ.", + "An 8 ch Nelaton bladder catheter was used as a mold.", + "The tubularised aorta segment was 5 cm long.", + "Three 7-0 Prolene interrupted stitches were used in the distal area.", + "Prolene 7-0 continuous suture was used in the rest of the patch.", + "E-E anastomosis to the damaged polar artery was done with interrupted 7-0 Prolene.", + "The recipient was a 68-year-old male.", + "The recipient had ESRD secondary to IgA nephropathy.", + "The recipient was on peritoneal dialysis.", + "The recipient had no other medical issues.", + "The recipient had no surgical procedures.", + "The patient was happy to proceed after a detailed discussion.", + "The patient signed the consent.", + "Transplant surgery was performed in the right iliac fossa.", + "An extraperitoneal approach to the iliac vessels was used.", + "The common cava patch was anastomosed to the recipient's external iliac vein.", + "The main artery was anastomosed to the common iliac artery.", + "The reconstructed artery with the tubulised patch was anastomosed to the external iliac artery.", + "The kidney was reperfused after completion of all three vascular anastomoses.", + "The ureter was anastomosed to the bladder over a double J stent.", + "A Robinson drain was left.", + "The wound was closed.", + "The cold ischemic time was 27 hours and 15 minutes.", + "The warm ischemic time was 75 minutes.", + "There were no immediate postoperative complications.", + "The first ultrasound was performed two hours after finishing the surgery.", + "The first ultrasound showed good perfusion of the kidney.", + "A second ultrasound was performed 48 hours after surgery.", + "A superficial haematoma within the subcutaneous tissues was reported.", + "Slightly reduced perfusion within the interpolar region was reported.", + "The appearance of the transplant kidney was otherwise satisfactory.", + "Haemoglobin fell from 11.2 to 6.4 gr/dl.", + "A decision to transfuse two units of blood cells was reached.", + "A relook surgery was performed.", + "Subcutaneous and perigraft haematoma was found.", + "No active bleeding was found.", + "The three vascular anastomoses were identified.", + "Both arteries, main and reconstructed, had good thrill.", + "The vein was soft and had good outflow.", + "A new drain was left at the surgical site.", + "Wound closure was performed.", + "Three days later, the ultrasound was repeated.", + "The right iliac fossa transplant kidney had normal cortical thickness and appearance.", + "There was no pelvicalyceal dilatation.", + "The previously demonstrated superficial collection was no longer present.", + "There was satisfactory global vascularity.", + "The sampled interlobular and arcuate vessels demonstrated normal flow.", + "Resistive indices were between 0.65 and 0.8.", + "The two renal arteries and veins had normal spectral waveforms.", + "The final impression was normal appearances of the right iliac fossa transplant kidney.", + "The ureteric stent was removed at week 4 after transplant.", + "Three months after transplantation the patient was stable.", + "The patient had no dialysis requirements.", + "The patient's creatinine was 187." + ], + "summary": "We present the case of a kidney transplant, in which the organ had an iatrogenic injury to a lower pole arterial branch during retrieval. The donor was a 35-year-old male (DCD, Maastricht III). The right kidney was accepted; it had three veins in a single cava patch and three renal arteries, the main artery with aorta patch that is 8 cm long. A small lower pole artery was sectioned during retrieval surgery at approximately 1 cm from its origin as well as a third small mid-lower pole artery. The lower pole damaged artery was reconstructed using tubularised aorta patch to a total length of 5 cm. No additional donor vessels had been sent. After construction of the tubulised aorta, E-E anastomosis to the damaged polar artery was done with interrupted 7-0 Prolene sutures.", + "summary_subclaims": [ + "The organ had an iatrogenic injury to a lower pole arterial branch during retrieval.", + "The donor was a 35-year-old male.", + "The donor was DCD, Maastricht III.", + "The right kidney was accepted.", + "The kidney had three veins in a single cava patch.", + "The kidney had three renal arteries.", + "The main artery had an aorta patch that is 8 cm long.", + "A small lower pole artery was sectioned during retrieval surgery at approximately 1 cm from its origin.", + "A third small mid-lower pole artery was sectioned during retrieval surgery.", + "The lower pole damaged artery was reconstructed using tubularised aorta patch to a total length of 5 cm.", + "No additional donor vessels had been sent.", + "After construction of the tubulised aorta, E-E anastomosis to the damaged polar artery was done with interrupted 7-0 Prolene sutures." + ] + }, + { + "id": "multiclinsum_test_656_en.txt", + "fulltext": "A 42-year-old man presented to Feiz Eye Hospital with sudden persistent painless loss of vision in April 2013. He had been diagnosed with GPA 10 months before. His presenting symptoms at that time were high fever and left eye redness along with nasal congestion, sinonasal obstruction, breathing difficulties, and joint pain. Laboratory tests revealed proteinuria. After physical examination, laboratory investigations, kidney biopsy, and imaging studies, GPA was diagnosed. The patient was hospitalized and treated with cyclophosphamide for 14 days. On discharge, he was prescribed high dose corticosteroid (prednisone: 100 mg daily) as a maintenance therapy.\nThe patient's symptoms improved until April 2013, when sudden severe visual loss in the left eye caused admission to the hospital. The patient described the sudden appearance of a black spot in his vision that spread all over his left visual field in 1 minute. He also had severe headache, redness of the left eye, and pain for three days.\nIn the ophthalmologic examination, visual acuity of the right eye was 10/10 and the left eye had only light perception. Relative afferent pupillary defect was positive in the left eye. Slit lamp examination was normal in the right eye but in the left eye there was a 4 mm round, fixed and painless mass in the upper eyelid . Conjunctiva was hyperemic, and an area of 2 mm necrotizing nodular scleritis in superonasal quadrant was noted . The cornea, iris, lens and vitreous cavity were normal. Intraocular pressure of the left eye was normal. Dilated funduscopic examination showed a white, swollen retina, particularly in the posterior pole, with a cherry-red spot. There was arterial attenuation and intravascular segmentation of the blood column in the posterior pole, but no emboli were noted [Figures and ].\nThe patient's description of painless, sudden loss of vision and appearance of the cherry-red spot on examination of the fundus indicated. Therefore, we gave him nasal O2, and performed ocular massage and paracentesis of the anterior chamber. The patient was hospitalized for 7 days and was treated with intravenous cyclophosphamide as per internal medicine consult. Aggressive lubrication of the ocular surface and frequent instillation of topical steroids and cycloplegics was prescribed. After several weeks, eyelid nodule and scleritis improved, but vision loss remained.", + "fulltext_subclaims": [ + "A 42-year-old man presented to Feiz Eye Hospital with sudden persistent painless loss of vision in April 2013.", + "He had been diagnosed with GPA 10 months before.", + "His presenting symptoms at that time were high fever and left eye redness along with nasal congestion, sinonasal obstruction, breathing difficulties, and joint pain.", + "Laboratory tests revealed proteinuria.", + "After physical examination, laboratory investigations, kidney biopsy, and imaging studies, GPA was diagnosed.", + "The patient was hospitalized and treated with cyclophosphamide for 14 days.", + "On discharge, he was prescribed high dose corticosteroid (prednisone: 100 mg daily) as a maintenance therapy.", + "The patient's symptoms improved until April 2013, when sudden severe visual loss in the left eye caused admission to the hospital.", + "The patient described the sudden appearance of a black spot in his vision that spread all over his left visual field in 1 minute.", + "He also had severe headache, redness of the left eye, and pain for three days.", + "In the ophthalmologic examination, visual acuity of the right eye was 10/10 and the left eye had only light perception.", + "Relative afferent pupillary defect was positive in the left eye.", + "Slit lamp examination was normal in the right eye.", + "In the left eye there was a 4 mm round, fixed and painless mass in the upper eyelid.", + "Conjunctiva was hyperemic.", + "An area of 2 mm necrotizing nodular scleritis in superonasal quadrant was noted.", + "The cornea, iris, lens and vitreous cavity were normal.", + "Intraocular pressure of the left eye was normal.", + "Dilated funduscopic examination showed a white, swollen retina, particularly in the posterior pole, with a cherry-red spot.", + "There was arterial attenuation and intravascular segmentation of the blood column in the posterior pole.", + "No emboli were noted.", + "The patient's description of painless, sudden loss of vision and appearance of the cherry-red spot on examination of the fundus indicated.", + "We gave him nasal O2, and performed ocular massage and paracentesis of the anterior chamber.", + "The patient was hospitalized for 7 days.", + "He was treated with intravenous cyclophosphamide as per internal medicine consult.", + "Aggressive lubrication of the ocular surface and frequent instillation of topical steroids and cycloplegics was prescribed.", + "After several weeks, eyelid nodule and scleritis improved.", + "Vision loss remained." + ], + "summary": "A 42-year-old man with a confirmed diagnosis of granulomatosis with polyangiitis was referred to the emergency room with sudden blurred vision. Eye examination showed hyperemic conjunctiva due to necrotizing scleritis in the superior nasal quadrant of the left eye, a mass in the left superior lid, as well as central retinal artery occlusion in the same eye.", + "summary_subclaims": [ + "The patient is a 42-year-old man.", + "The patient has a confirmed diagnosis of granulomatosis with polyangiitis.", + "The patient was referred to the emergency room with sudden blurred vision.", + "Eye examination showed hyperemic conjunctiva due to necrotizing scleritis in the superior nasal quadrant of the left eye.", + "A mass was found in the left superior lid.", + "Central retinal artery occlusion was present in the left eye." + ] + }, + { + "id": "multiclinsum_test_1856_en.txt", + "fulltext": "We report the case of a 59-year-old female patient of Southeast-Asian descent who underwent deceased donor renal transplantation at our institution in August 2016. At the time of initial referral for transplant evaluation in 2011, she had advanced chronic kidney disease but had not started dialysis. Medical records indicated that she had a slow rise in serum creatinine since 2006 but had never undergone a renal biopsy. No specific etiology had been ascribed to her kidney disease. Due to a history of 5 pregnancies that culminated in 3 live births and 2 miscarriages, she was broadly sensitized to human leukocyte antigens (HLA). Routine screening for anti-HLA antibodies with a Luminex-based solid-phase assay using single-antigen beads detected multiple class I and class II HLA antibodies in April 2016. Based on our institutional policy to denote HLA, to which antibodies of a strength greater than 4,000 mean fluorescence intensity (MFI) units are detected in the transplant candidate serum, as unacceptable, our patient's calculated panel reactive antibody (CPRA) level was 93%.\nAfter an approximate wait-time of 5 years, she received an organ offer from a 46-year-old male deceased donor, who succumbed to a self-inflicted gunshot wound to the head. The deceased donor had a terminal creatinine of 1.2 mg/dL, and the organ offered was assigned a kidney donor profile index of 38%. Pre-implantation biopsy of the transplanted kidney demonstrated glomerulosclerosis in 4 out of 78 sampled glomeruli. Fibrosis affecting up to 10% of the tubule interstitium, mild arteriosclerosis, and patchy areas of acute tubular necrosis were also noted. Donor and recipient were blood type compatible (ABO type A). Complement-dependent cytotoxicity and flow cytometry-based cross-match testing of the current recipient's serum with donor T and B lymphocytes were negative. However, donor-specific antibodies (DSA) to class I antigen-HLA B45 (MFI 3,182) and class II antigen-DQ6 (MFI 3,802) were detected by Luminex-based solid-phase assay in the serum sample from April 2016. We consider antibody strength of MFI 2,000 or greater to be clinically significant. Since this suggested prior sensitization to donor HLA, the risk of early antibody-mediated rejection (AMR) due to a memory B-cell response was predicted to be high. Transplant surgery was uneventful with minimal intra-operative blood loss, and the organ incurred a cold-ischemia time of 15 h.\nImmunosuppressive therapy for induction consisted of 6 mg/kg of intravenous (IV) antithymocyte globulin given in divided doses over 4 days; tapering doses of IV methylprednisolone given on postoperative days (PODs) 0–4. In addition, 375 mg/m2 of rituximab was administered on POD 1 to suppress humoral alloimmune response. For maintenance immunosuppressive therapy, the patient began receiving 1,000 mg of oral mycophenolate mofetil twice daily from POD 0. Excellent urine output of 1.3 L was noted in the first 12 h after transplant, and tacrolimus was initiated on POD 1. Tapering doses of oral prednisone were started on POD 5. The serum creatinine levels declined steadily from 7.9 mg/dL (pre-transplant) to 1.9 mg/dL by POD 5, and the patient did not require dialysis.\nHowever, the hemoglobin trended down to 6.8 g/dL (baseline: 9.8 g/dL), and the platelet count gradually decreased to 61,000/µL (baseline: 302,000/µL) by POD 6. Alarmingly, the patient's creatinine rose to 2.9 mg/dL and then to 3.3 mg/dL in the 24-h period between POD 5 and POD 6. Lactate dehydrogenase was elevated at 1,016 U/L (reference range: 313–618 U/L), and haptoglobin was <10 mg/dL (reference range: 30–200 mg/dL). The corresponding tacrolimus trough level was 5 ng/mL. Renal allograft ultrasound demonstrated mildly heterogeneous echotexture of the transplant kidney, and Doppler evaluation of the intraparenchymal vessels showed resistive indices ranging from 0.80 to 0.83. One unit of apheresis platelets was transfused, and the patient underwent an urgent ultrasound-guided renal allograft biopsy. In the 6 h preceding the biopsy, the patient's recorded urine output was 100 mL. The patient's blood pressure remained stable with a systolic blood pressure of approximately 140 mm Hg throughout the hospitalization leading up to the biopsy.\nAn adequate biopsy sample consisting of 2 cores of cortical tissue exhibiting 26 glomeruli and 4 interlobular arteries was obtained. No immediate biopsy-related complications occurred. The most prominent finding on light microscopic examination was the demonstration of fibrin thrombi involving 1 arteriole and capillary loops in 2 glomeruli . Isometric cytoplasmic vacuolization of tubular epithelial cells and arteriolar myocytes was also apparent. There was no evidence of microvascular or tubulointerstitial inflammation. C4d was negative by immunofluorescence microscopy. Electron microscopy revealed diffuse swelling of glomerular capillary endothelial cells and cytoplasmic vacuolization of tubular epithelial cells. Histologic correlates of acute AMR were striking in their absence. DSA that were scored positive in the pretransplant serum sample were not detectable in the serum sample tested on the day of the biopsy (HLA B45: pretransplant MFI 3,182 vs. POD 6 MFI 1,438; DQ6: pretransplant MFI 3,082 vs. POD 6 MFI 640). Histopathologic features noted on the renal allograft biopsy, taken together with clinical and laboratory findings, suggested that CNI-induced de novo post-transplant HUS was the most proximate cause of acute oliguric renal failure in this case .\nTacrolimus was discontinued. A reversal of the upward trend in creatinine was immediately apparent after withholding the CNI. Creatinine improved to 2.4, 1.8, and 1 mg/dL in the 3 succeeding days. The patient received a transfusion of 1 unit of packed red blood cells after the kidney biopsy following which hemoglobin improved from 6.8 to 8.6 g/dL and steadily improved to 10.1 g/dL in the following 2 weeks. In the same period, a significant improvement in platelet count occurred (61,000–348,000/µL). Substitution of tacrolimus with another CNI, cyclosporine (CsA), was considered, but we favored the introduction of maintenance immunosuppression with a costimulatory blocker, belatacept, instead, given emerging evidence of its efficacy in highly sensitized renal transplant recipients. The first dose of IV belatacept (5 mg/kg) was administered on POD 9 (3 days after the diagnosis of TMA). The patient received 5 mg/kg of IV belatacept every 2 weeks thereafter for 2 months and was then transitioned to a 5 mg/kg once monthly dosing regimen. Twelve months after transplant, she continues to have excellent renal allograft function with a serum creatinine of 0.7 mg/dL and has had no recurrence of hematologic abnormalities. Her most recent hemoglobin and platelet count were 12.3 g/dL and 271,000/µL, respectively .", + "fulltext_subclaims": [ + "The patient was a 59-year-old female of Southeast-Asian descent.", + "She underwent deceased donor renal transplantation in August 2016.", + "At the time of initial referral for transplant evaluation in 2011, she had advanced chronic kidney disease.", + "She had not started dialysis at the time of initial referral.", + "Medical records indicated a slow rise in serum creatinine since 2006.", + "She had never undergone a renal biopsy.", + "No specific etiology had been ascribed to her kidney disease.", + "She had a history of 5 pregnancies that culminated in 3 live births and 2 miscarriages.", + "She was broadly sensitized to human leukocyte antigens (HLA).", + "Routine screening for anti-HLA antibodies detected multiple class I and class II HLA antibodies in April 2016.", + "Based on institutional policy, HLA with antibodies of strength greater than 4,000 MFI units are denoted as unacceptable.", + "The patient's calculated panel reactive antibody (CPRA) level was 93%.", + "She received an organ offer from a 46-year-old male deceased donor.", + "The deceased donor succumbed to a self-inflicted gunshot wound to the head.", + "The deceased donor had a terminal creatinine of 1.2 mg/dL.", + "The organ offered was assigned a kidney donor profile index of 38%.", + "Pre-implantation biopsy of the transplanted kidney demonstrated glomerulosclerosis in 4 out of 78 sampled glomeruli.", + "Fibrosis affecting up to 10% of the tubule interstitium was noted.", + "Mild arteriosclerosis was noted.", + "Patchy areas of acute tubular necrosis were noted.", + "Donor and recipient were blood type compatible (ABO type A).", + "Complement-dependent cytotoxicity and flow cytometry-based cross-match testing were negative.", + "Donor-specific antibodies (DSA) to class I antigen-HLA B45 (MFI 3,182) and class II antigen-DQ6 (MFI 3,802) were detected.", + "Antibody strength of MFI 2,000 or greater is considered clinically significant.", + "This suggested prior sensitization to donor HLA.", + "The risk of early antibody-mediated rejection (AMR) due to a memory B-cell response was predicted to be high.", + "Transplant surgery was uneventful with minimal intra-operative blood loss.", + "The organ incurred a cold-ischemia time of 15 h.", + "Immunosuppressive therapy for induction consisted of 6 mg/kg of intravenous antithymocyte globulin given in divided doses over 4 days.", + "Tapering doses of IV methylprednisolone were given on postoperative days 0–4.", + "375 mg/m2 of rituximab was administered on postoperative day 1.", + "Maintenance immunosuppressive therapy included 1,000 mg of oral mycophenolate mofetil twice daily from postoperative day 0.", + "Excellent urine output of 1.3 L was noted in the first 12 h after transplant.", + "Tacrolimus was initiated on postoperative day 1.", + "Tapering doses of oral prednisone were started on postoperative day 5.", + "Serum creatinine levels declined from 7.9 mg/dL to 1.9 mg/dL by postoperative day 5.", + "The patient did not require dialysis.", + "The hemoglobin trended down to 6.8 g/dL by postoperative day 6.", + "The platelet count decreased to 61,000/µL by postoperative day 6.", + "Serum creatinine rose to 2.9 mg/dL and then to 3.3 mg/dL between postoperative days 5 and 6.", + "Lactate dehydrogenase was elevated at 1,016 U/L.", + "Haptoglobin was <10 mg/dL.", + "The corresponding tacrolimus trough level was 5 ng/mL.", + "Renal allograft ultrasound demonstrated mildly heterogeneous echotexture of the transplant kidney.", + "Doppler evaluation showed resistive indices ranging from 0.80 to 0.83.", + "One unit of apheresis platelets was transfused.", + "The patient underwent an urgent ultrasound-guided renal allograft biopsy.", + "The patient's recorded urine output was 100 mL in the 6 h preceding the biopsy.", + "The patient's blood pressure remained stable with a systolic blood pressure of approximately 140 mm Hg.", + "An adequate biopsy sample consisting of 2 cores of cortical tissue was obtained.", + "The biopsy sample exhibited 26 glomeruli and 4 interlobular arteries.", + "The most prominent finding on light microscopic examination was the demonstration of fibrin thrombi involving 1 arteriole and capillary loops in 2 glomeruli.", + "Isometric cytoplasmic vacuolization of tubular epithelial cells and arteriolar myocytes was apparent.", + "There was no evidence of microvascular or tubulointerstitial inflammation.", + "C4d was negative by immunofluorescence microscopy.", + "Electron microscopy revealed diffuse swelling of glomerular capillary endothelial cells.", + "Electron microscopy revealed cytoplasmic vacuolization of tubular epithelial cells.", + "Histologic correlates of acute AMR were striking in their absence.", + "DSA that were positive in the pretransplant serum sample were not detectable in the serum sample tested on the day of the biopsy.", + "Histopathologic features, clinical, and laboratory findings suggested CNI-induced de novo post-transplant HUS was the most proximate cause of acute oliguric renal failure.", + "Tacrolimus was discontinued.", + "A reversal of the upward trend in creatinine was immediately apparent after withholding the CNI.", + "Creatinine improved to 2.4, 1.8, and 1 mg/dL in the 3 succeeding days.", + "The patient received a transfusion of 1 unit of packed red blood cells after the kidney biopsy.", + "Hemoglobin improved from 6.8 to 8.6 g/dL.", + "Hemoglobin steadily improved to 10.1 g/dL in the following 2 weeks.", + "A significant improvement in platelet count occurred from 61,000 to 348,000/µL.", + "Substitution of tacrolimus with another CNI, cyclosporine, was considered.", + "The introduction of maintenance immunosuppression with belatacept was favored.", + "The first dose of IV belatacept (5 mg/kg) was administered on postoperative day 9.", + "The patient received 5 mg/kg of IV belatacept every 2 weeks for 2 months.", + "The patient was then transitioned to a 5 mg/kg once monthly dosing regimen.", + "Twelve months after transplant, she had excellent renal allograft function with a serum creatinine of 0.7 mg/dL.", + "She had no recurrence of hematologic abnormalities.", + "Her most recent hemoglobin was 12.3 g/dL.", + "Her most recent platelet count was 271,000/µL." + ], + "summary": "Here, we report the conversion of a highly sensitized renal transplant recipient with pretransplant donor-specific antibodies from tacrolimus to belatacept within 1 week of transplantation. This substitution was necessitated by the diagnosis of CNI-induced de novo post-transplant hemolytic uremic syndrome.", + "summary_subclaims": [ + "The patient was a highly sensitized renal transplant recipient.", + "The patient had pretransplant donor-specific antibodies.", + "The patient was converted from tacrolimus to belatacept within 1 week of transplantation.", + "The substitution was necessitated by the diagnosis of CNI-induced de novo post-transplant hemolytic uremic syndrome." + ] + }, + { + "id": "multiclinsum_test_2496_en.txt", + "fulltext": "We report the case of a 67-year-old woman who presented to our institute in August 2006 with a 2-month history of pain and swelling of the right hand and wrist, and a more recent onset of pain in the right shoulder. Her medical history included arterial hypertension and depression. Blood tests performed prior to hospitalization were unremarkable except for a high erythrocyte sedimentation rate (ESR) of 78 mm/hour. Plain radiography of the right hand showed osteoarthritis of the first carpometacarpal joint. Non-steroidal anti-inflammatory drugs and acetaminophen were given without significant improvement.\nOn physical examination, the fingers of the right hand were flexed, the right wrist was swollen and the right shoulder was extremely painful with a limited range of motion. Routine blood tests were normal but ESR was still high (46 mm/hour). A radiograph of the right shoulder showed demineralization of the humeral head and of the scapula, and an ultrasound study of the right shoulder, wrist and hand showed a supraspinatus tendinopathy without tendon tears and swelling of radiocarpal and intercarpal joints with marked power Doppler signal. SHS was suspected and a radionuclide scintigraphy was performed . The triphasic study of the right arm revealed an increased perfusion with increased and delayed activity of bone images, suggesting RSD of the wrist.\nHowever, the whole body study, which revealed diffuse spots of hyperfixation in the right humeral head and acromion, medial right clavicle, sternum, ribs, dorsal and lumbar spine and pelvis, was consistent with skeletal metastases. Magnetic resonance imaging (MRI) of the spine and pelvis confirmed the presence of multiple metastases located in the dorsal and lumbar spine, sacrum, pelvis and both femurs. The patient was treated with a single intravenous infusion of 90 mg pamidronate.\nFurther diagnostic studies were performed to identify the primary neoplasm. Mammography, thyroid ultrasound and lung computed tomography scan were unremarkable. Gastric endoscopy revealed an adenocarcinoma of the angular region. Despite chemotherapy, a radionuclide scan performed in November 2006 showed progression of the metastatic bone lesions. Signs and symptoms of SHS were completely resolved, but the images of the right hand were unmodified.", + "fulltext_subclaims": [ + "The patient was a 67-year-old woman.", + "She presented in August 2006.", + "She had a 2-month history of pain and swelling of the right hand and wrist.", + "She had a more recent onset of pain in the right shoulder.", + "Her medical history included arterial hypertension.", + "Her medical history included depression.", + "Blood tests prior to hospitalization were unremarkable except for a high erythrocyte sedimentation rate (ESR) of 78 mm/hour.", + "Plain radiography of the right hand showed osteoarthritis of the first carpometacarpal joint.", + "Non-steroidal anti-inflammatory drugs and acetaminophen were given.", + "There was no significant improvement with non-steroidal anti-inflammatory drugs and acetaminophen.", + "On physical examination, the fingers of the right hand were flexed.", + "The right wrist was swollen.", + "The right shoulder was extremely painful with a limited range of motion.", + "Routine blood tests were normal.", + "ESR was still high at 46 mm/hour.", + "A radiograph of the right shoulder showed demineralization of the humeral head.", + "A radiograph of the right shoulder showed demineralization of the scapula.", + "An ultrasound study of the right shoulder, wrist, and hand showed a supraspinatus tendinopathy without tendon tears.", + "An ultrasound study showed swelling of radiocarpal and intercarpal joints.", + "An ultrasound study showed marked power Doppler signal.", + "SHS was suspected.", + "A radionuclide scintigraphy was performed.", + "The triphasic study of the right arm revealed increased perfusion.", + "The triphasic study revealed increased and delayed activity of bone images.", + "The triphasic study suggested RSD of the wrist.", + "The whole body study revealed diffuse spots of hyperfixation in the right humeral head.", + "The whole body study revealed diffuse spots of hyperfixation in the acromion.", + "The whole body study revealed diffuse spots of hyperfixation in the medial right clavicle.", + "The whole body study revealed diffuse spots of hyperfixation in the sternum.", + "The whole body study revealed diffuse spots of hyperfixation in the ribs.", + "The whole body study revealed diffuse spots of hyperfixation in the dorsal and lumbar spine.", + "The whole body study revealed diffuse spots of hyperfixation in the pelvis.", + "The whole body study was consistent with skeletal metastases.", + "MRI of the spine and pelvis confirmed the presence of multiple metastases.", + "The metastases were located in the dorsal and lumbar spine.", + "The metastases were located in the sacrum.", + "The metastases were located in the pelvis.", + "The metastases were located in both femurs.", + "The patient was treated with a single intravenous infusion of 90 mg pamidronate.", + "Mammography was unremarkable.", + "Thyroid ultrasound was unremarkable.", + "Lung computed tomography scan was unremarkable.", + "Gastric endoscopy revealed an adenocarcinoma of the angular region.", + "A radionuclide scan performed in November 2006 showed progression of the metastatic bone lesions.", + "Signs and symptoms of SHS were completely resolved.", + "The images of the right hand were unmodified." + ], + "summary": "We report the case of a 67-year-old woman who presented with shoulder-hand syndrome as the initial manifestation of gastric cancer which had metastasized to bone.", + "summary_subclaims": [ + "The patient was a 67-year-old woman.", + "The patient presented with shoulder-hand syndrome.", + "Shoulder-hand syndrome was the initial manifestation of gastric cancer.", + "The gastric cancer had metastasized to bone." + ] + }, + { + "id": "multiclinsum_test_3267_en.txt", + "fulltext": "30-year-old male patient, resident of the city of Santa Cruz de la Sierra in Bolivia, engineer, man who has sex with man (HSH), promiscuous and with personal pathological history of HIV infection, diagnosed seven years ago, with adherence to antiretroviral therapy of great activity (TARGA, dolutegravir, lamivudine and tenofovir), since the beginning of 2018.\n\nOn August 8, 2022, he reported unprotected sexual activity (without condom) with a stranger, then four days later he presented a papule with well-defined edges in the left gluteal region, near the intergluteal cleft and three centimeters from the gluteal groove (first day, August 12), with pruritus. In addition, he presented rectal tenesmus and tenesmus, with non-fetid mucopurulent discharge and pain during defecation. For this reason, he decided to go to the National Center for Tropical Diseases (CENETROP) on August 15, 2022.\n\nOn physical examination (day 3), 15 lesions, including papules and pustules, were observed in the gluteal region of varying sizes, less than 1 cm. In addition, an erythematous papule was identified in the lower third of the left thigh (sartorius) and a pustule in the neck. There were also bilateral, symmetric, painless, mobile, and slightly indurated superficial and deep cervical lymphadenopathies. The dermatological lesions were sampled, with pharyngeal and anal swabs, the latter to rule out sexually transmitted infections. The diagnosis of VS was confirmed by real-time polymerase chain reaction (RT-PCR). He was referred to his corresponding health center, and blood chemistry, serological, and other tests were performed.\n\nIsolation and home monitoring twice a week (Monday and Thursday) was decided. On the seventh day, two solitary lesions appeared: a pustule in the left lateral region of the neck and an erythematous papule in the left costal rib. On the eleventh day, all lesions were erythematous-pustular in the gluteal region and neck, and some pustules were observed umbilicated. In addition, the patient reported that the lesions in the gluteal region were painful. On the fourteenth day, most lesions were in the scab phase and painless. A papule appeared near the gluteal cleft. On the eighteenth day, several scabs were observed. On the twenty-first day, all scabs fell off and discharge was decided.\n\nIn view of these findings, the following nosological entities were proposed: VS with HIV, gonorrhea, latent syphilis and infectious proctitis (IP). From the fifth day, general measures were indicated such as home isolation, frequent disinfection, daily washing of towels, clothing and bed at a temperature of 60°C, drying of lesions with a towel specific for the affected areas, and another towel for the rest of the body. Empirical and symptomatic pharmacological treatment was indicated with ceftriaxone 1 g single dose intramuscularly (IM); benzathine penicillin G 2.4 million IU, once a week for three weeks IM; transfer factor (HEBERTRANS®) twice a week IM for eight weeks; doxycycline 100 mg twice daily orally (VO) for seven days; vitamin D3 150 000 IU single dose orally; vitamin C 1 g every eight hours orally; fexofenadine 180 mg once a day orally; tramadol 325 mg/paracetamol 37.5 mg three times a day orally; Roydil (calcium dobesilate, lidocaine anhydride, hydrocortisone acetate and zinc oxide) once a day rectally. After three days of the application of ceftriaxone, the patient had improvement of the tenesmus and straining.\n", + "fulltext_subclaims": [ + "The patient is a 30-year-old male.", + "The patient is a resident of Santa Cruz de la Sierra in Bolivia.", + "The patient is an engineer.", + "The patient is a man who has sex with men (HSH).", + "The patient has a personal pathological history of HIV infection.", + "The patient's HIV was diagnosed seven years ago.", + "The patient is adhering to antiretroviral therapy.", + "The patient's antiretroviral therapy includes TARGA, dolutegravir, lamivudine, and tenofovir.", + "The patient has been on antiretroviral therapy since the beginning of 2018.", + "On August 8, 2022, the patient reported unprotected sexual activity without a condom.", + "Four days after the sexual activity, the patient developed a papule with well-defined edges in the left gluteal region.", + "The papule was located near the intergluteal cleft and three centimeters from the gluteal groove.", + "The papule appeared on August 12, 2022.", + "The patient experienced pruritus.", + "The patient had rectal tenesmus.", + "The patient had non-fetid mucopurulent discharge.", + "The patient had pain during defecation.", + "The patient went to the National Center for Tropical Diseases (CENETROP) on August 15, 2022.", + "On physical examination on day 3, 15 lesions were observed in the gluteal region.", + "The lesions included papules and pustules.", + "The lesions in the gluteal region were of varying sizes, less than 1 cm.", + "An erythematous papule was identified in the lower third of the left thigh.", + "A pustule was identified in the neck.", + "Bilateral, symmetric, painless, mobile, and slightly indurated superficial and deep cervical lymphadenopathies were observed.", + "The dermatological lesions were sampled.", + "Pharyngeal and anal swabs were taken.", + "The anal swab was to rule out sexually transmitted infections.", + "The diagnosis of VS was confirmed by real-time polymerase chain reaction (RT-PCR).", + "The patient was referred to his corresponding health center.", + "Blood chemistry, serological, and other tests were performed.", + "Isolation and home monitoring twice a week (Monday and Thursday) were decided.", + "On the seventh day, two solitary lesions appeared.", + "A pustule appeared in the left lateral region of the neck.", + "An erythematous papule appeared in the left costal rib.", + "On the eleventh day, all lesions were erythematous-pustular in the gluteal region and neck.", + "Some pustules were observed umbilicated.", + "The patient reported that the lesions in the gluteal region were painful.", + "On the fourteenth day, most lesions were in the scab phase and painless.", + "A papule appeared near the gluteal cleft.", + "On the eighteenth day, several scabs were observed.", + "On the twenty-first day, all scabs fell off.", + "Discharge was decided.", + "The proposed nosological entities included VS with HIV.", + "The proposed nosological entities included gonorrhea.", + "The proposed nosological entities included latent syphilis.", + "The proposed nosological entities included infectious proctitis (IP).", + "General measures included home isolation.", + "General measures included frequent disinfection.", + "General measures included daily washing of towels, clothing, and bed at a temperature of 60°C.", + "General measures included drying of lesions with a towel specific for the affected areas.", + "General measures included another towel for the rest of the body.", + "Empirical and symptomatic pharmacological treatment was indicated.", + "Ceftriaxone 1 g single dose intramuscularly was indicated.", + "Benzathine penicillin G 2.4 million IU, once a week for three weeks intramuscularly was indicated.", + "Transfer factor (HEBERTRANS®) twice a week intramuscularly for eight weeks was indicated.", + "Doxycycline 100 mg twice daily orally for seven days was indicated.", + "Vitamin D3 150 000 IU single dose orally was indicated.", + "Vitamin C 1 g every eight hours orally was indicated.", + "Fexofenadine 180 mg once a day orally was indicated.", + "Tramadol 325 mg/paracetamol 37.5 mg three times a day orally was indicated.", + "Roydil (calcium dobesilate, lidocaine anhydride, hydrocortisone acetate, and zinc oxide) once a day rectally was indicated.", + "After three days of the application of ceftriaxone, the patient had improvement of the tenesmus and straining." + ], + "summary": "A patient with a history of HIV was presented with exanthems in various regions of the body, with a greater concentration in the gluteal region, associated with cervical adenopathies and infectious proctitis. The sample of the dermatological lesions was taken for the molecular study of real-time polymerase chain reaction (RT-PCR), which confirmed the diagnosis of VS. Infection with Treponema pallidum and Neisseria gonorrhoeae was identified by serology and culture of anal secretion, respectively. Specific antibiotic treatment for gonorrhea and syphilis was applied, and VS responded favorably to symptomatic and immunomodulatory therapy.\n", + "summary_subclaims": [ + "The patient had a history of HIV.", + "The patient had exanthems in various regions of the body.", + "The exanthems were more concentrated in the gluteal region.", + "The patient had cervical adenopathies.", + "The patient had infectious proctitis.", + "A sample of the dermatological lesions was taken for RT-PCR.", + "The RT-PCR confirmed the diagnosis of VS.", + "Infection with Treponema pallidum was identified by serology.", + "Infection with Neisseria gonorrhoeae was identified by culture of anal secretion.", + "Specific antibiotic treatment for gonorrhea and syphilis was applied.", + "VS responded favorably to symptomatic and immunomodulatory therapy." + ] + }, + { + "id": "multiclinsum_test_462_en.txt", + "fulltext": "A 79-year-old gentleman presented with a 3-week history of acute, progressively worsening right-sided back pain radiating to the right groin and anterior thigh. He was admitted due to reduced mobility secondary to pain and an inability to safely function independently at home. A risk assessment for red flag symptoms including spinal cord or cauda equina compression, progressive neurological deficits, new urinary retention, faecal incontinence, and constitutional symptoms were absent. He was in his usual state of health prior to the onset of these symptoms. He denied any history of fevers, rigors, gastrointestinal symptoms, inciting trauma, or recent dental or surgical procedures. Social history included a 30-pack-year smoking history, minimal alcohol use, and denied intravenous substance use. His past medical history included hypertension, dyslipidaemia, gout and reflux. His past surgical history involved bilateral hernia repair with mesh, bilateral subclavian to carotid artery bypass and repair of an endovascular infrarenal abdominal aortic aneurysm, which required embolization for a leak at the left internal iliac artery 4 years later. Home medications included Clopidogrel, Hydrochlorothiazide, Perindopril, Allopurinol, Pantoprazole, Rosuvastatin, and Tamsulosin. There was no history of immunosuppression or use of immune modulating medications, particularly glucocorticoids. He denied any recent travel, animal exposures, consumption of processed meats, cheeses or other dairy products.\nThe patient was afebrile and hemodynamically stable at presentation and throughout his hospital stay. Physical examination of the cardiorespiratory, abdominal, and neurological systems was within normal limits. A focused examination revealed no tenderness on spinal palpation, a negative straight leg raise test, no pain on leg roll, and a normal gait. Relevant laboratory results included lymphopenia (0.7 × 109/L), anaemia (haemoglobin 101 g/L), LDH of 202 U/L, and CRP 34.9 mg/L, which later increased to 87.9 mg/L. Multiple sets of blood cultures were repeatedly negative. During his admission, he had an episode of self-resolving diarrhea. Interestingly, despite no prior antibiotic exposure, a stool sample was positive for C. difficile toxin by PCR. This, however, was more representative of a colonisation rather than a true infection.\nRadiographs of the hip and pelvis showed multi-level degenerative disc disease without evidence of fracture. CT Chest/Abdomen/Pelvis with endovascular protocol was negative for endoleak or dissection, but incidentally demonstrated interval L3-L4 discitis with destruction of associated endplates. Transthoracic echocardiogram effectively ruled out the presence of valve disease or vegetations. An MRI with gadolinium was subsequently performed and confirmed the diagnosis of L3-L4 discitis and osteomyelitis . Given the clinical stability and a lack of clear causative pathogen on blood culture, antibiotic administration was delayed to accommodate a fluoroscopy-guided percutaneous aspiration and biopsy. Fluid aspirate returned positive for Listeria monocytogenes in broth culture. Fungal and mycobacterial cultures remained negative. L. monocytogenes was thus determined to be the aetiology and the patient was started on a 6-week course of Ampicillin, with rapid clinical improvement and normalization of CRP on serial assessment. The patient was subsequently seen in follow-up with both the Infectious Disease and Vascular Surgery services at 2- and 6-month time points with ongoing clinical recovery and no recurrence of disease.", + "fulltext_subclaims": [ + "The patient is a 79-year-old gentleman.", + "He had a 3-week history of acute, progressively worsening right-sided back pain radiating to the right groin and anterior thigh.", + "He was admitted due to reduced mobility secondary to pain.", + "He was unable to safely function independently at home.", + "A risk assessment for red flag symptoms was performed.", + "Red flag symptoms including spinal cord or cauda equina compression were absent.", + "Progressive neurological deficits were absent.", + "New urinary retention was absent.", + "Faecal incontinence was absent.", + "Constitutional symptoms were absent.", + "He was in his usual state of health prior to the onset of symptoms.", + "He denied any history of fevers.", + "He denied any history of rigors.", + "He denied any history of gastrointestinal symptoms.", + "He denied any inciting trauma.", + "He denied any recent dental or surgical procedures.", + "His social history included a 30-pack-year smoking history.", + "He had minimal alcohol use.", + "He denied intravenous substance use.", + "His past medical history included hypertension.", + "His past medical history included dyslipidaemia.", + "His past medical history included gout.", + "His past medical history included reflux.", + "His past surgical history involved bilateral hernia repair with mesh.", + "His past surgical history involved bilateral subclavian to carotid artery bypass.", + "His past surgical history included repair of an endovascular infrarenal abdominal aortic aneurysm.", + "The abdominal aortic aneurysm required embolization for a leak at the left internal iliac artery 4 years later.", + "His home medications included Clopidogrel.", + "His home medications included Hydrochlorothiazide.", + "His home medications included Perindopril.", + "His home medications included Allopurinol.", + "His home medications included Pantoprazole.", + "His home medications included Rosuvastatin.", + "His home medications included Tamsulosin.", + "He had no history of immunosuppression.", + "He denied any recent travel.", + "He denied any animal exposures.", + "He denied any consumption of processed meats.", + "He denied any consumption of cheeses or other dairy products.", + "The patient was afebrile at presentation.", + "The patient was hemodynamically stable at presentation.", + "Physical examination of the cardiorespiratory system was within normal limits.", + "Physical examination of the abdominal system was within normal limits.", + "Physical examination of the neurological system was within normal limits.", + "A focused examination revealed no tenderness on spinal palpation.", + "The straight leg raise test was negative.", + "There was no pain on leg roll.", + "The gait was normal.", + "Laboratory results included lymphopenia (0.7 × 109/L).", + "Laboratory results included anaemia (haemoglobin 101 g/L).", + "Laboratory results included LDH of 202 U/L.", + "Laboratory results included CRP 34.9 mg/L.", + "CRP later increased to 87.9 mg/L.", + "Multiple sets of blood cultures were repeatedly negative.", + "He had an episode of self-resolving diarrhea.", + "A stool sample was positive for C. difficile toxin by PCR.", + "The C. difficile toxin positivity was more representative of a colonisation rather than a true infection.", + "Radiographs of the hip and pelvis showed multi-level degenerative disc disease.", + "Radiographs showed no evidence of fracture.", + "CT Chest/Abdomen/Pelvis with endovascular protocol was negative for endoleak.", + "CT Chest/Abdomen/Pelvis with endovascular protocol was negative for dissection.", + "CT incidentally demonstrated interval L3-L4 discitis with destruction of associated endplates.", + "Transthoracic echocardiogram ruled out the presence of valve disease.", + "Transthoracic echocardiogram ruled out the presence of vegetations.", + "An MRI with gadolinium confirmed the diagnosis of L3-L4 discitis.", + "An MRI with gadolinium confirmed the diagnosis of L3-L4 osteomyelitis.", + "Antibiotic administration was delayed to accommodate a fluoroscopy-guided percutaneous aspiration and biopsy.", + "Fluid aspirate returned positive for Listeria monocytogenes in broth culture.", + "Fungal cultures remained negative.", + "Mycobacterial cultures remained negative.", + "L. monocytogenes was determined to be the aetiology.", + "The patient was started on a 6-week course of Ampicillin.", + "The patient had rapid clinical improvement.", + "CRP normalized on serial assessment.", + "The patient was seen in follow-up with both the Infectious Disease and Vascular Surgery services.", + "The follow-up occurred at 2- and 6-month time points.", + "The patient had ongoing clinical recovery.", + "There was no recurrence of disease." + ], + "summary": "A 79-year-old male presents with acute-on-chronic back pain in the absence of risk factors or exposures, aside from age. On radiological imaging, spondylodiscitis of L3-L4 was diagnosed. Subsequently, a CT-guided biopsy was performed to aid in confirming microbiological aetiology. Listeria monocytogenes was grown in culture and patient received appropriate antibacterial therapy.", + "summary_subclaims": [ + "A 79-year-old male presents with acute-on-chronic back pain.", + "The patient has no risk factors or exposures aside from age.", + "Radiological imaging diagnosed spondylodiscitis of L3-L4.", + "A CT-guided biopsy was performed.", + "Listeria monocytogenes was grown in culture.", + "The patient received appropriate antibacterial therapy." + ] + }, + { + "id": "multiclinsum_test_2776_en.txt", + "fulltext": "A 56-year-old woman, 70 kg, of Algerian origin was referred to us in August 2003 presenting with fatigue, proximal and bilateral muscular weakness (muscle testing score of 69 points compared to a score of 88 in healthy individuals), apprehension to grasp, and difficulties in getting dressed. Additional symptoms included effort dyspnea, swollen hands, and purple erythema of her eyelids. Appendicitis, sciatica, tachycardia, hypertension, and asthma were listed in her medical history. Her creatine phosphokinase (CPK, muscle enzymes) levels were six times the normal (N) level. Auto-antibodies measurements were initially not performed.\nA muscle biopsy was performed, and showed characteristic patterns of dermatomyositis with perifascicular atrophy, evidence of injury to capillaries and perifascicular myofibers, and inflammatory infiltrates in the perimysial region (predominantly CD4+). She was diagnosed as having dermatomyositis in November 2003 and prednisone treatment (1 mg/kg per day) was initiated. A repeated search for malignancy was negative. A diagnosis of a mild interstitial pneumonitis together with the presence of anti-Jo1 antibodies further confirmed the suspicion of aSS. Her gamma globulin levels were normal.\nSince treatment response was incomplete, immunosuppressant therapy with azathioprine (2 mg/kg per day), which was replaced after 9 months by MTX (15 mg per week), was introduced. However, both were poorly tolerated and she developed cytopenia. Therefore, infusions with IVIg (2 g/kg per month) were initiated for six months, in addition to steroids.\nIn September 2006, due to lack of response to these different therapies, RTX (2 g every 6 months) was introduced and our patient reported an improvement in her articular and muscular pain. Yet, because of the development of hypogammaglobulinemia, RTX was discontinued in October 2011. Of importance, no immune deficit had been present prior to the introduction of RTX.\nShe was readmitted in December 2012 with a muscle weakness score of 75.5 points (over 88 points in healthy individuals) . Her CPK levels were normal, but probing for anti-Jo-1 antibody was positive. In addition, a lung scan revealed the presence of interstitial basal lung infiltrate . Testing of pulmonary function showed a reduction of single-breath diffusion capacity for carbon monoxide (DLCO; 48%), with a total lung capacity (TLC) of 72%, and forced expiratory volume in 1 second (FEV1)/vital capacity (VC) at 73%. A slight muscle inflammation of her thighs was also evidenced by magnetic resonance imaging (MRI). In terms of treatment strategy, a bolus injection of IVIg (2 g/kg) was administered, but she developed adverse effects, including headache and distal paresthesia, after which she refused to receive another IVIg infusion. Her treatment adherence was poor and in addition to refusing to try a different IVIg formulation, she had also resumed the corticosteroid treatment in November 2012. In fact, she expressed wishes against hospitalizations and stopped all the treatments.\nAn immunologic evaluation showed hypogammaglobulinemia (4.4 g/l), with reduced total immunoglobulin G (IgG) (4.2 g/l), and a reduction in each subclass of IgG: IgG1 2.48 g/l (N >3.82 g/l), IgG2 1.65 g/l (N >2.41), IgG3 0.14 g/l (N >0.2), and IgG4 0.038 g/l (N >0.18 g/l). Her IgA (0.5 g/l, N >0.7) and IgM levels (0.34 g/l, N >0.4) were also decreased. Her IgE levels were normal.\nShe was seen again in May 2014, when her general health had deteriorated due to the discontinuation of steroids, RTX, and IgG treatment. In particular, she complained about severe fatigue and presented with swelling of the proximal interphalangeal joints of her right index and middle finger. An MRI scan of her right hand revealed an advanced and destructive arthropathy associated with significant synovitis of the proximal interphalangeal joints of the first, second, and third rays and, to a lesser extent, of the fourth and fifth rays . Her metacarpal phalangeal joints were not affected, but an erosive synovitis of the dorsal scapholunate articulation and beginning erosion of the lunate were observed. Her radioulnar joint was not affected.\nAt this point, her muscle weakness score was 70/88, with a muscle strength of +3 as measured bilaterally at her middle trapezius, major gluteal, and psoas muscles. Her muscle disability was rated 18/75 (score ranging from 0 no disability to 75 maximum disability) . An MRI of her thighs did not reveal any significant evolution of myopathy since the previous examination in 2012. In particular, there was no important inflammatory signal of the muscle and no sign of amyotrophy.\nLikewise, a thorax scan confirmed the stabilization of the abnormalities reported in November 2012, with mostly the basal regions being affected. Pulmonary function testing was also indicative of overall stability compared to 2012: single-breath DLCO was 46%, TLC 70%, and FEV1/VC 73%. Whereas DLCO, TLC (−30%), and functional respiratory deficit (25%) were unchanged, a slight decrease of forced expiratory flow (FEF)25–75 was noted.\nOf importance, she complained of frequent infections of the upper airways, including pharyngitis, sinusitis, bronchitis, and otitis for the past 2 years. Consistent with these recurrent infections, an immunologic evaluation confirmed a persistent hypogammaglobulinemia (5.0 g/l), with reduced total IgG (4.1 g/l), and reduction of each subclass of IgG: IgG1 2.3 g/l, IgG2 1.48 g/l, IgG3 0.11 g/l, and IgG4 0.04 g/l. This picture was evocative of a persistent common variable immunodeficiency (CVID) secondary to RTX. Her C-reactive protein (CRP) level was 22.7 mg/l and her CPK level was 489 UI/l.\nTreatment with Gammanorm® (SCIg) was initiated in July 2014 (2 g/kg per month divided into two infusions per week). After 3 and 6 months, respectively, of treatment, she reported diffuse pain, which was present since discontinuation of Cortancyl® (prednisone), and general fatigue. Arthritis of her proximal and metacarpal phalangeal joints was still present, but her muscle weakness score had improved to 75/88 and muscle disability was rated 12/75 . Of importance, no novel infectious episode was reported. In fact, Gammanorm® (SCIg) was well tolerated and she confirmed a slight improvement in her general health state.\nIn January 2015, MTX (15 mg/week) was reintroduced and a significant clinical improvement was achieved by April. Notably, her serum CRP (3.3 mg/l) and CPK (63 UI/l) returned to normalized levels despite persisting fatigue, along with arthritis of her metacarpal and proximal interphalangeal joints (arthritis confirmed at a consultation in May 2015). Nevertheless, the normalization of her immunodeficiency and the significant improvement in the state of her general health remained stable, as reassessed in November 2015.\nFinally, in May 2016, joint manifestations had disappeared and fatigue had regressed significantly. No infection had been observed during the past 18 months. Her muscle weakness score had also improved to 82/88 and muscle disability was rated 9/75. Her CRP and CPK levels were normal. As shown by immunologic evaluation, hypogammaglobulinemia had resolved and all subclasses of IgG were normalized.\nMoreover, the results of a thorax scan indicated a slight improvement in basal lung infiltrate, alongside pulmonary function testing: DLCO of 55%, TLC of 75%, and a FEV1/VC 74%.", + "fulltext_subclaims": [ + "The patient was a 56-year-old woman of Algerian origin.", + "She was referred in August 2003.", + "She presented with fatigue.", + "She had proximal and bilateral muscular weakness.", + "Her muscle testing score was 69 points.", + "Her score was compared to 88 in healthy individuals.", + "She had apprehension to grasp.", + "She had difficulties in getting dressed.", + "She had effort dyspnea.", + "She had swollen hands.", + "She had purple erythema of her eyelids.", + "Her medical history included appendicitis.", + "Her medical history included sciatica.", + "Her medical history included tachycardia.", + "Her medical history included hypertension.", + "Her medical history included asthma.", + "Her creatine phosphokinase levels were six times the normal level.", + "Auto-antibodies measurements were initially not performed.", + "A muscle biopsy was performed.", + "The biopsy showed characteristic patterns of dermatomyositis.", + "The biopsy showed perifascicular atrophy.", + "The biopsy showed evidence of injury to capillaries.", + "The biopsy showed evidence of injury to perifascicular myofibers.", + "The biopsy showed inflammatory infiltrates in the perimysial region.", + "The inflammatory infiltrates were predominantly CD4+.", + "She was diagnosed with dermatomyositis in November 2003.", + "She was started on prednisone treatment at 1 mg/kg per day.", + "A repeated search for malignancy was negative.", + "A diagnosis of mild interstitial pneumonitis was made.", + "The presence of anti-Jo1 antibodies further confirmed the suspicion of aSS.", + "Her gamma globulin levels were normal.", + "Immunosuppressant therapy with azathioprine at 2 mg/kg per day was introduced.", + "Azathioprine was replaced after 9 months by MTX at 15 mg per week.", + "Both azathioprine and MTX were poorly tolerated.", + "She developed cytopenia.", + "Infusions with IVIg at 2 g/kg per month were initiated for six months.", + "In September 2006, RTX at 2 g every 6 months was introduced.", + "She reported improvement in articular and muscular pain after RTX.", + "RTX was discontinued in October 2011 due to hypogammaglobulinemia.", + "No immune deficit had been present prior to RTX.", + "She was readmitted in December 2012.", + "Her muscle weakness score was 75.5 points.", + "Her CPK levels were normal.", + "Anti-Jo-1 antibody testing was positive.", + "A lung scan revealed interstitial basal lung infiltrate.", + "Pulmonary function testing showed a reduction of single-breath diffusion capacity for carbon monoxide (DLCO) to 48%.", + "Total lung capacity (TLC) was 72%.", + "Forced expiratory volume in 1 second (FEV1)/vital capacity (VC) was 73%.", + "MRI showed slight muscle inflammation of her thighs.", + "A bolus injection of IVIg at 2 g/kg was administered.", + "She developed headache and distal paresthesia after IVIg.", + "She refused another IVIg infusion.", + "Her treatment adherence was poor.", + "She refused to try a different IVIg formulation.", + "She resumed corticosteroid treatment in November 2012.", + "She expressed wishes against hospitalizations.", + "She stopped all treatments.", + "An immunologic evaluation showed hypogammaglobulinemia at 4.4 g/l.", + "Total IgG was reduced to 4.2 g/l.", + "IgG1 was 2.48 g/l.", + "IgG2 was 1.65 g/l.", + "IgG3 was 0.14 g/l.", + "IgG4 was 0.038 g/l.", + "IgA was 0.5 g/l.", + "IgM was 0.34 g/l.", + "IgE levels were normal.", + "She was seen again in May 2014.", + "Her general health had deteriorated due to discontinuation of steroids, RTX, and IgG treatment.", + "She complained of severe fatigue.", + "She had swelling of the proximal interphalangeal joints of her right index and middle finger.", + "An MRI of her right hand showed advanced and destructive arthropathy.", + "The MRI showed significant synovitis of the proximal interphalangeal joints of the first, second, and third rays.", + "The MRI showed synovitis of the fourth and fifth rays to a lesser extent.", + "Her metacarpal phalangeal joints were not affected.", + "Erosive synovitis of the dorsal scapholunate articulation was observed.", + "Beginning erosion of the lunate was observed.", + "Her radioulnar joint was not affected.", + "Her muscle weakness score was 70/88.", + "Her muscle strength was +3 bilaterally at her middle trapezius, major gluteal, and psoas muscles.", + "Her muscle disability was rated 18/75.", + "An MRI of her thighs did not show significant evolution of myopathy since 2012.", + "There was no important inflammatory signal of the muscle.", + "There was no sign of amyotrophy.", + "A thorax scan confirmed stabilization of abnormalities reported in November 2012.", + "Basal regions were mostly affected.", + "Pulmonary function testing showed overall stability compared to 2012.", + "Single-breath DLCO was 46%.", + "TLC was 70%.", + "FEV1/VC was 73%.", + "DLCO, TLC, and functional respiratory deficit were unchanged.", + "A slight decrease of forced expiratory flow (FEF)25–75 was noted.", + "She complained of frequent infections of the upper airways.", + "She had pharyngitis, sinusitis, bronchitis, and otitis for the past 2 years.", + "An immunologic evaluation confirmed persistent hypogammaglobulinemia at 5.0 g/l.", + "Total IgG was reduced to 4.1 g/l.", + "IgG1 was 2.3 g/l.", + "IgG2 was 1.48 g/l.", + "IgG3 was 0.11 g/l.", + "IgG4 was 0.04 g/l.", + "This picture was evocative of persistent common variable immunodeficiency (CVID) secondary to RTX.", + "Her C-reactive protein (CRP) level was 22.7 mg/l.", + "Her CPK level was 489 UI/l.", + "Treatment with Gammanorm® (SCIg) at 2 g/kg per month was initiated in July 2014.", + "She reported diffuse pain and general fatigue after 3 and 6 months of treatment.", + "Arthritis of her proximal and metacarpal phalangeal joints was still present.", + "Her muscle weakness score improved to 75/88.", + "Her muscle disability was rated 12/75.", + "No novel infectious episode was reported.", + "Gammanorm® was well tolerated.", + "She confirmed a slight improvement in her general health state.", + "MTX at 15 mg/week was reintroduced in January 2015.", + "A significant clinical improvement was achieved by April.", + "Her serum CRP returned to 3.3 mg/l.", + "Her CPK returned to 63 UI/l.", + "Her CRP and CPK levels were normalized despite persisting fatigue.", + "Arthritis of her metacarpal and proximal interphalangeal joints was confirmed in May 2015.", + "The normalization of her immunodeficiency and improvement in general health remained stable in November 2015.", + "In May 2016, joint manifestations had disappeared.", + "Fatigue had regressed significantly.", + "No infection had been observed during the past 18 months.", + "Her muscle weakness score improved to 82/88.", + "Her muscle disability was rated 9/75.", + "Her CRP and CPK levels were normal.", + "Hypogammaglobulinemia had resolved.", + "All subclasses of IgG were normalized.", + "A thorax scan showed a slight improvement in basal lung infiltrate.", + "Pulmonary function testing showed DLCO of 55%.", + "TLC was 75%.", + "FEV1/VC was 74%." + ], + "summary": "Here, we describe the case of a 56-year-old woman of Algerian origin. She is the first case of a patient with multidrug-resistant antisynthetase syndrome featuring pulmonary involvement and arthropathy, and chronic secondary immune deficiency with recurrent infections, after anti-CD20 treatment, in which her primary antisynthetase syndrome-related symptoms and secondary immune deficiency were treated successfully with subcutaneous administration of immunoglobulin. The administration of immunoglobulin subcutaneously was introduced at a dose of 2 g/kg per month and was well tolerated. Clinical improvement was observed within 3 months of initiation of subcutaneous administration of immunoglobulin. After 22 months of treatment, she showed a significant improvement in terms of muscle strength, pulmonary involvement, arthralgia, and immunodeficiency. Her serum creatine phosphokinase and C-reactive protein levels remained normal. Finally, she was compliant and entirely satisfied with the treatment.", + "summary_subclaims": [ + "The patient is a 56-year-old woman of Algerian origin.", + "She is the first case of a patient with multidrug-resistant antisynthetase syndrome.", + "The patient had pulmonary involvement.", + "The patient had arthropathy.", + "The patient had chronic secondary immune deficiency.", + "The patient had recurrent infections.", + "The patient's immune deficiency occurred after anti-CD20 treatment.", + "The patient's primary antisynthetase syndrome-related symptoms were treated with subcutaneous administration of immunoglobulin.", + "The patient's secondary immune deficiency was treated with subcutaneous administration of immunoglobulin.", + "The subcutaneous administration of immunoglobulin was introduced at a dose of 2 g/kg per month.", + "The subcutaneous administration of immunoglobulin was well tolerated.", + "Clinical improvement was observed within 3 months of initiation of subcutaneous administration of immunoglobulin.", + "After 22 months of treatment, the patient showed significant improvement in muscle strength.", + "After 22 months of treatment, the patient showed significant improvement in pulmonary involvement.", + "After 22 months of treatment, the patient showed significant improvement in arthralgia.", + "After 22 months of treatment, the patient showed significant improvement in immunodeficiency.", + "Her serum creatine phosphokinase levels remained normal.", + "Her C-reactive protein levels remained normal.", + "She was compliant with the treatment.", + "She was entirely satisfied with the treatment." + ] + }, + { + "id": "multiclinsum_test_2597_en.txt", + "fulltext": "A 78-year-old male patient was admitted to the hospital following a 1-month history of unexplained fever, thrill, weight-loss and general malaise, and a 1-week complaint of pollakiuria.\nTwelve years prior to this episode, the patient was diagnosed with a non-muscle-invasive bladder carcinoma that was treated by transurethral resection followed by BCG instillations (Oncotice, Merck, USA). These instillations were repeated after 7, 8 and 11 years due to oncological relapse. The last BCG instillation was administered 5 months before admission.\nThe medical history of the patient further included hypertension, and atrial fibrillation for which he received anti-vitamin K therapy. He was in remission of a prostate cancer for which he had received radiotherapy and anti-androgen therapy 4 years earlier.\nOn admission, clinical examination was unremarkable. Laboratory workup revealed inflammation (CRP elevated at 5.7 mg/dL), hematuria and leucocyturia. Urine culture was positive for Escherichia coli and cefuroxime antibiotherapy was initiated according to the drug susceptibility profile.\nAs fever was persisting 72 h after initiation of antibiotic therapy, a urinary tract ultrasound (US) was performed in order to exclude an obstacle or an abcess. US revealed a large abdominal aortic aneurysm, which was subsequently confirmed by computed tomography (CT). The size of the aneurysm was measured at 7 × 7 × 7.3 cm and located in the infra-renal region . This image was not present on a CT performed 3 years earlier. Antibiotic therapy was stopped and blood cultures were collected.\nFour days after admission, the patient fell during the night. A second abdominal CT revealed a large retroperitoneal hematoma but no sign of rupture was observed. After multi-disciplinary discussion, the patient underwent surgery. Perioperative samples were sent to the bacteriology laboratory for conventional and mycobacterial cultures.\nDirect smear of the aneurysm was positive for acid-fast bacilli. Direct PCR was not performed, as current Belgian guidelines do not recommend to perform this test on non-pulmonary samples. Both liquid cultures (MGIT, Becton–Dickinson, Baltimore, MD, USA) and solid cultures (Löwenstein-Jensen media, Beckton Dickison, Baltimore, MD, USA) were positive. Following internal procedures and the manufacturer’s instructions, rapid identification of the positive mycobacterial culture was performed using the BD MGIT TBc Identification Test© (Beckton Dickinson Diagnostic, USA), an immunochromatographic assay based on the detection of the Mycobacterium tuberculosis MPB 64 antigen. The result was negative for Mycobacterium tuberculosis complex. After review of the medical record, BCGosis was suspected, and the PCR-based Xpert MTB/Rif assay (Cepheid, USA) was performed on the positive culture and gave a positive result for M. tuberculosis complex. M.bovis BCG identification was later confirmed by the Belgian national reference center which performed a second PCR targeting CSB and RD1 .\nManagement of M. bovis mycotic aneurysms include both surgical replacement with an aortic graft material and 9–12 months antimycobacterial therapy including isoniazid, rifampicine and ethambutol . Pyrazinamide is not used due to intrinsic resistance of M. bovis to this drug. Antimycobacterial therapy decreases the risk of relapse following surgery .\nAs a result, anti-tuberculosis therapy with rifampicine, ethambutol, isoniazide and pyrazinamide was started in our patient. Pyrazinamide was discontinued upon definitive identification of BCG. After 2 months, ethambutol was discontinued and rifampicin and isoniazide were pursued for additional 7 months. The patient showed no signs of relapse after two-years of follow up. The clinical examination and the CT were normal at that time.", + "fulltext_subclaims": [ + "The patient was a 78-year-old male.", + "The patient had a 1-month history of unexplained fever.", + "The patient had a 1-week complaint of pollakiuria.", + "The patient was diagnosed with non-muscle-invasive bladder carcinoma 12 years prior.", + "The bladder carcinoma was treated by transurethral resection followed by BCG instillations.", + "The BCG instillations were repeated after 7, 8, and 11 years due to oncological relapse.", + "The last BCG instillation was administered 5 months before admission.", + "The patient had a history of hypertension.", + "The patient had atrial fibrillation.", + "The patient received anti-vitamin K therapy.", + "The patient was in remission of prostate cancer.", + "The patient had received radiotherapy and anti-androgen therapy for prostate cancer 4 years earlier.", + "On admission, clinical examination was unremarkable.", + "Laboratory workup revealed CRP elevated at 5.7 mg/dL.", + "Laboratory workup revealed hematuria.", + "Laboratory workup revealed leucocyturia.", + "Urine culture was positive for Escherichia coli.", + "Cefuroxime antibiotherapy was initiated according to the drug susceptibility profile.", + "Fever was persisting 72 h after initiation of antibiotic therapy.", + "A urinary tract ultrasound was performed.", + "The ultrasound revealed a large abdominal aortic aneurysm.", + "The aneurysm was confirmed by computed tomography.", + "The size of the aneurysm was measured at 7 × 7 × 7.3 cm.", + "The aneurysm was located in the infra-renal region.", + "This image was not present on a CT performed 3 years earlier.", + "Antibiotic therapy was stopped.", + "Blood cultures were collected.", + "Four days after admission, the patient fell during the night.", + "A second abdominal CT revealed a large retroperitoneal hematoma.", + "No sign of rupture was observed.", + "The patient underwent surgery.", + "Perioperative samples were sent to the bacteriology laboratory.", + "Direct smear of the aneurysm was positive for acid-fast bacilli.", + "Direct PCR was not performed.", + "Current Belgian guidelines do not recommend performing PCR on non-pulmonary samples.", + "Both liquid cultures and solid cultures were positive.", + "Rapid identification of the positive mycobacterial culture was performed using the BD MGIT TBc Identification Test.", + "The result was negative for Mycobacterium tuberculosis complex.", + "BCGosis was suspected.", + "The Xpert MTB/Rif assay was performed on the positive culture.", + "The Xpert MTB/Rif assay gave a positive result for M. tuberculosis complex.", + "M. bovis BCG identification was later confirmed by the Belgian national reference center.", + "Management of M. bovis mycotic aneurysms includes surgical replacement with an aortic graft material.", + "Management includes 9–12 months antimycobacterial therapy.", + "Antimycobacterial therapy decreases the risk of relapse following surgery.", + "Anti-tuberculosis therapy with rifampicine, ethambutol, isoniazide, and pyrazinamide was started.", + "Pyrazinamide was discontinued upon definitive identification of BCG.", + "After 2 months, ethambutol was discontinued.", + "Rifampicin and isoniazide were pursued for additional 7 months.", + "The patient showed no signs of relapse after two-years of follow up.", + "The clinical examination and the CT were normal at that time." + ], + "summary": "We report the case of a 78-year-old male patient who was admitted to the hospital because of a 1-month history of unexplained fever, thrill, weight-loss and general malaise. His past medical history was marked by a non-muscle-invasive bladder carcinoma treated by transurethral resection followed by BCG instillations (Oncotice, Merck, USA). The patient was initially treated for a urinary tract infection but as fever persists after 72 h of antibiotherapy, urinary tract ultrasound was performed and revealed a large abdominal aortic aneurysm confirmed by computed tomography. Surgery was performed after multidisciplinary discussion. Direct smear of perioperative samples revealed acid-fast bacilli and both solid and liquid cultures were massively positive. Rapid identification of the positive mycobacterial culture was performed using an immunochromatographic assay based on the detection of the Mycobacterium tuberculosis MPB 64 antigen. The result was negative for Mycobacterium tuberculosis complex. After review of the medical record, a polymerase chain reaction (PCR) was performed and gave a positive result for M. tuberculosis complex. Anti-tuberculosis therapy was started immediately and the patient evolved favorably.", + "summary_subclaims": [ + "The patient was a 78-year-old male.", + "The patient had a 1-month history of unexplained fever.", + "The patient had a past medical history of non-muscle-invasive bladder carcinoma.", + "The bladder carcinoma was treated by transurethral resection followed by BCG instillations.", + "The patient was initially treated for a urinary tract infection.", + "Fever persisted after 72 h of antibiotherapy.", + "Urinary tract ultrasound revealed a large abdominal aortic aneurysm.", + "Computed tomography confirmed the abdominal aortic aneurysm.", + "Surgery was performed after multidisciplinary discussion.", + "Direct smear of perioperative samples revealed acid-fast bacilli.", + "Both solid and liquid cultures were massively positive.", + "Rapid identification of the positive mycobacterial culture was performed using an immunochromatographic assay.", + "The immunochromatographic assay detected the Mycobacterium tuberculosis MPB 64 antigen.", + "The result was negative for Mycobacterium tuberculosis complex.", + "A polymerase chain reaction (PCR) was performed.", + "The PCR gave a positive result for M. tuberculosis complex.", + "Anti-tuberculosis therapy was started immediately.", + "The patient evolved favorably." + ] + }, + { + "id": "multiclinsum_test_2978_en.txt", + "fulltext": "A 39-year-old male was transferred to our hospital from another hospital. He had mild tenderness, an obvious bowel pattern and hyperactive bowel sounds; he was able to pass gas occasionally. Before admission, he suffered progressive abdominal distention and gradual deterioration, and he developed malnutrition for two months. A total alimentary tract angiography showed partial enlargement of the ascending colon and transverse colon and partial dilation of the distal small intestine . He was diagnosed with “adult megacolon” and recommended for surgical treatment. However, the operation was not performed because of a significant decrease in platelets (with a minimum of 19 × 109/L) and severe malnutrition. He had been in a car accident 2 years previously. He was the driver and was wearing a seat belt at the time of the accident. During that admission, he was always conscious and was found to have left clavicle fractures and multiple rib fractures. Abdominal examination showed seat belt marks and mild localized tenderness at the site of the abrasions. An abdominal CT scan showed a small amount of fluid (approximately 150 ml) in the abdominal cavity with no solid organ abnormalities. He was hemodynamically stable and was able to pass gas and defecate. He improved rapidly with conservative treatment, was discharged after several days and was asymptomatic. Two months after discharge, he started to have episodes of abdominal distension and intermittent mild tenderness, and he passed gas less frequently than before. However, he improved rapidly again after receiving treatment with traditional Chinese medicine.\nAfter admission, we first tried to improve the general condition of the patient by strengthening parenteral nutrition and correcting electrolyte imbalances. Then, a series of additional examinations were performed to explore the possible reasons for these problems. An abdominal CT scan showed an abrupt narrowing zone at the jejunum . Small balloon colonoscopy found a narrow zone approximately 40–50 cm from the ileocecal valve; the surface mucosa was swollen and erosive, and the upper segment of the intestine was obviously expanded . Laparoscopy was performed on the patient after multidisciplinary discussion and detailed preoperative evaluation. We found severe adhesion between the abdominal wall and intestine as well as a narrow small bowel with a length of 12 cm at approximately 40–50 cm from the ileocecal valve. The mesentery corresponding to the narrow part of the small intestine was also absent, and the proximal intestine was markedly dilatated. Additionally, a thick adhesive band was also found between the dilated proximal intestine and the sigmoid colon, and we thought it might be the main cause of colonic dilation . Therefore, we performed laparoscopic adhesiolysis and partial small bowel resection, and the thick adhesive bands were destroyed. The narrow small bowel with length of 20 cm was removed. Histologically, the area was fibrotic . The patient recovered rapidly and gained 5 kg in the 3 months after surgery. He was very satisfied with the treatment.", + "fulltext_subclaims": [ + "The patient was a 39-year-old male.", + "He was transferred to our hospital from another hospital.", + "He had mild tenderness.", + "He had an obvious bowel pattern.", + "He had hyperactive bowel sounds.", + "He was able to pass gas occasionally.", + "Before admission, he suffered progressive abdominal distention.", + "Before admission, he had gradual deterioration.", + "He developed malnutrition for two months.", + "A total alimentary tract angiography showed partial enlargement of the ascending colon.", + "A total alimentary tract angiography showed partial enlargement of the transverse colon.", + "A total alimentary tract angiography showed partial dilation of the distal small intestine.", + "He was diagnosed with 'adult megacolon'.", + "He was recommended for surgical treatment.", + "The operation was not performed because of a significant decrease in platelets.", + "The minimum platelet count was 19 × 109/L.", + "The operation was not performed because of severe malnutrition.", + "He had been in a car accident 2 years previously.", + "He was the driver at the time of the accident.", + "He was wearing a seat belt at the time of the accident.", + "During that admission, he was always conscious.", + "He was found to have left clavicle fractures.", + "He was found to have multiple rib fractures.", + "Abdominal examination showed seat belt marks.", + "Abdominal examination showed mild localized tenderness at the site of the abrasions.", + "An abdominal CT scan showed a small amount of fluid in the abdominal cavity.", + "The abdominal fluid was approximately 150 ml.", + "The abdominal CT scan showed no solid organ abnormalities.", + "He was hemodynamically stable.", + "He was able to pass gas.", + "He was able to defecate.", + "He improved rapidly with conservative treatment.", + "He was discharged after several days.", + "He was asymptomatic after discharge.", + "Two months after discharge, he started to have episodes of abdominal distension.", + "Two months after discharge, he had intermittent mild tenderness.", + "He passed gas less frequently than before.", + "He improved rapidly again after receiving treatment with traditional Chinese medicine.", + "After admission, we first tried to improve the general condition of the patient.", + "We strengthened parenteral nutrition.", + "We corrected electrolyte imbalances.", + "A series of additional examinations were performed.", + "An abdominal CT scan showed an abrupt narrowing zone at the jejunum.", + "Small balloon colonoscopy found a narrow zone approximately 40–50 cm from the ileocecal valve.", + "The surface mucosa was swollen.", + "The surface mucosa was erosive.", + "The upper segment of the intestine was obviously expanded.", + "Laparoscopy was performed after multidisciplinary discussion.", + "Laparoscopy was performed after detailed preoperative evaluation.", + "We found severe adhesion between the abdominal wall and intestine.", + "We found a narrow small bowel with a length of 12 cm at approximately 40–50 cm from the ileocecal valve.", + "The mesentery corresponding to the narrow part of the small intestine was also absent.", + "The proximal intestine was markedly dilatated.", + "A thick adhesive band was found between the dilated proximal intestine and the sigmoid colon.", + "We thought the thick adhesive band might be the main cause of colonic dilation.", + "We performed laparoscopic adhesiolysis.", + "We performed partial small bowel resection.", + "The thick adhesive bands were destroyed.", + "The narrow small bowel with length of 20 cm was removed.", + "Histologically, the area was fibrotic.", + "The patient recovered rapidly.", + "The patient gained 5 kg in the 3 months after surgery.", + "He was very satisfied with the treatment." + ], + "summary": "A 39-year-old male was transferred to our hospital from another hospital complaints of progressive abdominal distension and severe weakness. In the previous hospital, he was diagnosed with \"adult megacolon\" and was recommended for surgical treatment. In our hospital, he was diagnosed with delayed bowel obstruction due to seat belt injury and underwent surgical intervention. Following laparoscopic adhesiolysis and resection of the narrow small intestine, his symptoms improved rapidly, and he was discharged.", + "summary_subclaims": [ + "The patient is a 39-year-old male.", + "The patient was transferred to our hospital from another hospital.", + "The patient had complaints of progressive abdominal distension.", + "The patient had complaints of severe weakness.", + "In the previous hospital, he was diagnosed with 'adult megacolon'.", + "In the previous hospital, he was recommended for surgical treatment.", + "In our hospital, he was diagnosed with delayed bowel obstruction due to seat belt injury.", + "He underwent surgical intervention.", + "He underwent laparoscopic adhesiolysis.", + "He underwent resection of the narrow small intestine.", + "His symptoms improved rapidly following surgery.", + "He was discharged." + ] + }, + { + "id": "multiclinsum_test_345_en.txt", + "fulltext": "A 78-year-old female with hypertension, hyperlipidaemia, coronary artery disease, and atrial fibrillation, presented with shortness of breath over the last several months. She is unaware of any significant diseases in her family, and she had no major surgeries except for vaginal hysterectomy, which was uneventful.\nPhysical examination on admission indicated signs of mild heart failure with a continuous holosystolic murmur at the cardiac apex and rales at the base of the lung. Chest X-ray shows mild pulmonary oedema and a significant dilated left heart silhouette . Transoesophageal echocardiography (TOE) indicated a left ventricle (LV) ejection fraction of 50%, severely dilated left atrium (LA) and right atrium (RA), severe mitral regurgitation with malcoaptation, and centrally directed flow jets, and mild to moderate tricuspid regurgitation (Video 1). The proximal isovelocity surface area derived effective regurgitant orifice area measured 0.43 cm2 with LV end-systolic diameter of 42 mm.\nA cardiac heart team discussed all treatment options, including valve replacement surgery, percutaneous valve repair (PMVR) using a clip, and transcatheter mitral valve replacement (TMVR) study trial. The patient underwent an abdominal and chest computed tomography (CT) angiogram to assess the feasibility of TMVR, which indicated large MV dimensions excluding her from the procedure. No other major abnormal findings were reported on CT except for cholelithiasis and suspected renal cysts.\nConsidering the patient’s high mortality risk for surgery (3.96% by the Society of Thoracic Surgeons score), unfavourable anatomy for TMVR, and patient preference, we decided to proceed with a PMVR using an edge-to-edge technique.\nUnder ultrasound guidance, we introduced a 6 Fr sheath into the right femoral vein using a micropuncture catheter and confirmed its location by angiography.\nWhile ascending, the wire took an abnormal path on the left side of the chest and beyond the cardiac silhouette and then downwards towards the RA . A multipurpose catheter showed RA trace and a flow-jet directed to the left side supporting the location right-sided chambers (Video 2). Transoesophageal echocardiography confirmed that the trajectory was from the superior vena cava (SVC) to the RA without passing through the IVC-RA junction . Given this, we decided to stop the procedure as it cannot safely be performed.\nRetrospective analysis of the CT revealed an interruption of the IVC at the level of the hepatic segment. The IVC was drained directly into dilated azygos veins along with the hemiazygos and the accessory veins and entered the RA via the SVC. The massive enlargement of the LA led to significant compression of the azygos vein before draining to the SVC ( and corresponding , Video 3, ).\nThe patient was referred to surgery, where the mitral and the tricuspid valves were repaired successfully and discharged home in good health. Two months following the surgery, the patient reported a significant improvement in daily life activity and denied exertional dyspnoea. She engaged in cardiac rehabilitation and felt much better than before the surgery.", + "fulltext_subclaims": [ + "The patient is a 78-year-old female.", + "She has hypertension.", + "She has hyperlipidaemia.", + "She has coronary artery disease.", + "She has atrial fibrillation.", + "She presented with shortness of breath over the last several months.", + "She is unaware of any significant diseases in her family.", + "She had a vaginal hysterectomy, which was uneventful.", + "Physical examination on admission indicated signs of mild heart failure.", + "Chest X-ray shows mild pulmonary oedema.", + "Transoesophageal echocardiography indicated a left ventricle ejection fraction of 50%.", + "The proximal isovelocity surface area derived effective regurgitant orifice area measured 0.43 cm2.", + "The patient underwent an abdominal and chest computed tomography angiogram.", + "CT indicated large MV dimensions excluding her from TMVR.", + "The patient's mortality risk for surgery was 3.96% by the Society of Thoracic Surgeons score.", + "We decided to proceed with a PMVR using an edge-to-edge technique.", + "A 6 Fr sheath was introduced into the right femoral vein.", + "The wire took an abnormal path on the left side of the chest.", + "Transoesophageal echocardiography confirmed the trajectory was from the superior vena cava to the right atrium.", + "Retrospective analysis of the CT revealed an interruption of the IVC at the level of the hepatic segment.", + "The patient was referred to surgery.", + "The mitral and the tricuspid valves were repaired successfully.", + "The patient was discharged home in good health.", + "Two months following the surgery, the patient reported a significant improvement in daily life activity.", + "She engaged in cardiac rehabilitation." + ], + "summary": "A 78-year-old female presented with severe and symptomatic mitral regurgitation. The heart team decided to proceed with a percutaneous option, considering the patient's high surgical risk. While ascending from the femoral vein, the wire took an abnormal course to the left side of the vertebrae and continued beyond the cardiac silhouette downwards the right atrium (RA). We decided to abort the procedure due to the high risk for vascular complications assuming the need to cross it with the device's delivery system. Retrospective computed tomography analysis revealed an interrupted IVC at the level of the renal vasculature and azygos continuation toward the RA via a dilated superior vena cava. The patient was referred to surgery and had successful mitral and tricuspid valve repair and was discharged home in good health.", + "summary_subclaims": [ + "The patient is a 78-year-old female.", + "The patient had severe and symptomatic mitral regurgitation.", + "The heart team decided to proceed with a percutaneous option.", + "The wire took an abnormal course to the left side of the vertebrae.", + "The wire continued beyond the cardiac silhouette downwards the right atrium.", + "The procedure was aborted due to the high risk for vascular complications.", + "Retrospective computed tomography analysis revealed an interrupted IVC at the level of the renal vasculature.", + "The patient was referred to surgery.", + "The patient had successful mitral and tricuspid valve repair.", + "The patient was discharged home in good health." + ] + }, + { + "id": "multiclinsum_test_376_en.txt", + "fulltext": "A 61-year-old female patient was referred to our hospital to undergo surgical resection of colon cancer. She underwent bilateral mastectomy for breast cancer and implantation of a central venous port system via the left subclavian vein for chemotherapy 16 years ago in another institution. In addition, she has been suffering from pulmonary hypertension for 10 years. At the preoperative workup, a chest radiograph revealed a broken central venous catheter fragment in the heart. According to a retrospective review of the chest radiographs, disruption of the catheter occurred at least 3.5 years ago. The catheter fragment was found to be lodged mainly in the right atrium on computed tomography (CT), and both ends located in the right atrial appendage and the left hepatic vein were inaccessible .\nPercutaneous retrieval of the catheter fragment was performed as follows: under local anesthesia, the right femoral vein was punctured and a 10-Fr sheath 25 cm in length (Supersheath®, Medikit Co. Ltd., Tokyo, Japan) was placed in the inferior vena cava (IVC). A 6-F snare catheter with a 25-mm-diameter loop (Amplatz Gooseneck Snare™, Medtronic, Minneapolis, MN, USA) was advanced into the hepatic segment of the IVC and opened in advance. Then, an angled 4-F pigtail catheter (Optiflash®, Terumo Co., Tokyo, Japan) was inserted over a 0.035-in guidewire (Radifocus®, Terumo Co., Tokyo, Japan) into the sheath side-by-side with the snare catheter. The pigtail catheter was advanced into the right atrium passing through the snare loop under multi-directional fluoroscopic guidance . The catheter fragment was then hooked and pulled inferiorly by the pigtail catheter . As a result, the inferior end of the catheter fragment disengaged from the left hepatic vein and fell into the IVC through the snare loop . Instantly, the snare loop tightened the catheter fragment at the initial position . Repositioning of the snare catheter was not necessary throughout the procedure. When the catheter fragment was being removed from the body, the pigtail catheter was first pulled into the sheath to ensure sufficient clearance to pull the folded catheter fragment into the sheath. The administration of local anesthesia to the withdrawal of the sheath took 26 min. Fluoroscopy time was 4.6 min. The dose area product was 8640 mGycm2 and air kerma was 68.12 mGy.", + "fulltext_subclaims": [ + "The patient is a 61-year-old female.", + "The patient was referred to undergo surgical resection of colon cancer.", + "The patient underwent bilateral mastectomy for breast cancer.", + "The patient had a central venous port system implanted via the left subclavian vein.", + "The central venous port system was implanted 16 years ago.", + "The central venous port system was implanted in another institution.", + "The patient has been suffering from pulmonary hypertension for 10 years.", + "A chest radiograph revealed a broken central venous catheter fragment in the heart.", + "Disruption of the catheter occurred at least 3.5 years ago.", + "The catheter fragment was found to be lodged mainly in the right atrium on computed tomography.", + "Both ends of the catheter fragment were inaccessible.", + "Percutaneous retrieval of the catheter fragment was performed.", + "The right femoral vein was punctured under local anesthesia.", + "A 10-Fr sheath 25 cm in length was placed in the inferior vena cava.", + "A 6-F snare catheter with a 25-mm-diameter loop was advanced into the hepatic segment of the IVC.", + "The snare catheter was opened in advance.", + "An angled 4-F pigtail catheter was inserted over a 0.035-in guidewire into the sheath side-by-side with the snare catheter.", + "The pigtail catheter was advanced into the right atrium passing through the snare loop under multi-directional fluoroscopic guidance.", + "The catheter fragment was hooked and pulled inferiorly by the pigtail catheter.", + "The inferior end of the catheter fragment disengaged from the left hepatic vein.", + "The catheter fragment fell into the IVC through the snare loop.", + "The snare loop tightened the catheter fragment at the initial position.", + "Repositioning of the snare catheter was not necessary throughout the procedure.", + "When the catheter fragment was being removed from the body, the pigtail catheter was first pulled into the sheath.", + "The administration of local anesthesia to the withdrawal of the sheath took 26 min.", + "Fluoroscopy time was 4.6 min.", + "The dose area product was 8640 mGycm2.", + "The air kerma was 68.12 mGy." + ], + "summary": "A 61-year-old female patient underwent removal of a central venous catheter fragment migrating to the right atrium. Both ends located in the right atrial appendage and left hepatic vein were inaccessible. Initially, a snare loop was opened in the inferior vena cava and a pigtail catheter was advanced through the snare loop to hook the catheter fragment. The free end was created by pulling the pigtail catheter, dragged automatically into the snare loop, grasped, and retrieved immediately.", + "summary_subclaims": [ + "A 61-year-old female patient underwent removal of a central venous catheter fragment migrating to the right atrium.", + "Both ends located in the right atrial appendage and left hepatic vein were inaccessible.", + "Initially, a snare loop was opened in the inferior vena cava.", + "A pigtail catheter was advanced through the snare loop to hook the catheter fragment.", + "The free end was created by pulling the pigtail catheter.", + "The catheter fragment was dragged automatically into the snare loop.", + "The catheter fragment was grasped.", + "The catheter fragment was retrieved immediately." + ] + }, + { + "id": "multiclinsum_test_284_en.txt", + "fulltext": "A 60-year-old Japanese man with a 9-year history of T2DM presented at the emergency department of Kariya Toyota General Hospital with anuria and severe general fatigue. On admission, the patient was transported by ambulance due to his difficulty in moving. On evaluation, the patient reported fatigue, malaise, weight loss, and intermittent nausea and vomiting. He reported no headaches, joint, or muscle pain. He denied having a fever or contact with another sick individual.\nApart from T2DM, his past medical history included hypertension and lumbar disc herniation. He had no history of psychiatric disease and no known drug allergies. He had no family history of diabetes mellitus, lived alone, and his educational status was not obtained. The patient had smoked 1 pack of cigarettes per day for 45 years and consumed approximately 540 mL of Japanese sake daily. His medications included Met (500 mg three times daily), sitagliptin (50 mg once daily), pioglitazone (15 mg once daily), dapagliflozin (5 mg once daily), amlodipine (5 mg once daily), azilsartan/amlodipine (20 mg/5 mg once daily), rosuvastatin (2.5 mg once daily), and a hydrogel patch containing loxoprofen sodium.\nRenal function was normal before admission and the Met dosage used to treat T2DM was suitable for this patient. No abnormality was found in the patient’s blood tests (data not shown) when he had visited his doctor 13 days before admission. Notably, 12 days before admission, his work had changed from office to physical work (approximately 30,000–40,000 steps per day). He had noted a gradual decrease in urinary output for several days before admission, but had no other symptoms. Two days before admission, he developed anuria, dizziness, and nausea.\nThe initial laboratory findings are shown in Table . The time-course changes in serum creatinine and blood urea nitrogen (BUN) levels after admission are shown in Fig. . The lactate concentration of the patient was 4.27 mmol/L and the arterial pH was 7.31. Considering the previously established definition for lactic acidosis (lactate > 5 mmol/L and pH < 7.35) , the patient did not meet these criteria. However, a recently updated definition of lactic acidosis revealed that this patient taking Met fulfilled the criteria for the diagnosis of lactic acidosis because the lactate concentration was > 4 mmol/L .\nThe physical examination at admission indicated the following: height of 172.3 cm, weight of 69.3 kg, blood pressure of 159/94 mmHg, regular pulse of 96 beats per minute, body temperature of 36.3 °C, and oxygen saturation of 99% breathing ambient air. There was no sign of hypoglycemia since blood glucose was 129 mg/dL . This case is considered to be different from either diabetic ketoacidosis or euglycemic diabetic ketoacidosis. Despite the presence of normal glucose levels, he was not in the insulin-dependent state characteristic of euglycemic diabetic ketoacidosis and did not present with the physical symptoms of ketosis (tachypnea, nausea, vomiting, abdominal pain, and impaired consciousness). The patient was alert and appeared well. Cardiac auscultation revealed a regular rhythm without murmurs or gallops and an audible S1 and S2. Respiratory sounds were clear to auscultation with no crackles, wheezes, or bronchial breath sounds. The abdomen was non-distended, soft, and non-tender. His legs had no edema or muscle weakness, and the remainder of the examination was unremarkable.\nA radiograph of the chest was normal. Computed tomography (CT) showed slight cortical atrophy in the bilateral kidneys; however, no kidney stone or hydronephrosis was observed. There was irregular thickening of the small bowel wall without adjacent fat stranding and no sign of inferior vena cava collapse.\nBilateral hydronephrosis and nephrolithiasis were excluded based on the CT scan data. Glomerulonephritis was also excluded based on the negative autoantibody findings. The ratio of urea nitrogen to creatinine was < 20, suggesting a possible cause for the intrinsic renal injury. There was no hematuria because the presence of red cells in the urine was due the trauma induced by urinary bladder catheterization on admission. Considering the low estimated glomerular filtration rate (eGFR) and high urinary protein/creatinine ratio (11.04 g/g Cre), urinary N-acetyl-β-d-glucosaminidase (420.3 U/g Cre), and β2-microglobulin/creatinine ratio (149 µg/g Cre) , the patient was presumptively diagnosed with acute tubular necrosis with metabolic acidosis (anion-gap 23.5 mmol/L). Renal pathology findings on day 3 after admission revealed that 3 of 23 glomeruli were sclerotic and no significant pathological alterations were observed with light microscopy. However, the proximal tubular cells were diffusely enlarged with vacuolar degeneration. The same pathology may be seen with Fabry’s disease and use of osmotic diuretics, but the patient’s history was negative. All immunofluorescence results were negative and, apart from the vacuolization and swelling of the proximal tubules, no obvious abnormal findings were observed by electron microscopy. Based on the pathological findings and clinical course, the diagnosis of acute tubular necrosis was confirmed.\nAfter admission, intravenous hydration therapy was started. On the day of presentation at the emergency unit (day 0), he was hospitalized and hemodialysis (HD) was introduced to remove Met and improve acid–base disruption and anuria. In detail, HD was performed with a polysulfone dialyzer [Pinnafine® PN-100 (filter size 1.0 m2, Fresenius Medical Care AG and Co., Hessen, Germany) (at day 0, 1, and 3 with small molecule heparin) or Pinnafine® PN-140 (filter size 1.4 m2, Fresenius Medical Care AG and Co., Hessen, Germany) (at day 5 and 7 with Nafamostat Mesilate)] with blood and dialysate (Kidaly 4E solution, Fuso Pharmaceutical Industries, Ltd., Osaka, Japan) flow rates of 150 and 500 mL/min, respectively, for 3 hours per session. During the HD session, the patient’s condition was stable. The eGFR was calculated from serum creatinine levels on days 0, 3, 5, 7, 10, and 19 were 5.1, 4.5, 10.8, 31.9, 61.2, and 59.9 mL/min/1.73 m2, respectively . The patient resumed urination on day 2. On day 5, anuria was recovered after the third session of HD. Renal function gradually improved, and on day 11, the serum creatinine level reached 1.78 mg/dL. The patient was discharged 13 days after hospitalization, and no major prognostic problems were observed.\nThe plasma concentrations of Met were measured using high-performance liquid chromatography (HPLC)–ultraviolet (UV) as per a previous report , with slight modification and in accordance with the validation criteria guidelines of the US Food and Drug Administration . The Met concentrations on days 3, 5, and 7 were 8.95, 2.58, and 0.16 µg/mL, respectively. The semilogarithmic concentration–time plots for Met showed good linearity (R2 = 0.954, Fig. D). The one-compartment model pharmacokinetic (PK) analysis yielded an observed ke (day 3–7) of 0.04 hours−1 and calculated t1/2 (day 3–7) of 16.5 hours. Moreover, the t1/2 (day 3–5) was 26.7 hours, and t1/2 (day 5–7) was 11.9 hours.", + "fulltext_subclaims": [ + "The patient is a 60-year-old Japanese man.", + "The patient had a 9-year history of T2DM.", + "The patient presented with anuria.", + "The patient reported intermittent nausea and vomiting.", + "The patient denied having a fever.", + "The patient had no history of psychiatric disease.", + "The patient had smoked 1 pack of cigarettes per day for 45 years.", + "The patient consumed approximately 540 mL of Japanese sake daily.", + "The patient's medications included Met (500 mg three times daily).", + "The patient's medications included sitagliptin (50 mg once daily).", + "The patient's medications included pioglitazone (15 mg once daily).", + "The patient's medications included dapagliflozin (5 mg once daily).", + "The patient's medications included amlodipine (5 mg once daily).", + "The patient's medications included azilsartan/amlodipine (20 mg/5 mg once daily).", + "The patient's medications included rosuvastatin (2.5 mg once daily).", + "The patient's medications included a hydrogel patch containing loxoprofen sodium.", + "The patient had noted a gradual decrease in urinary output for several days before admission.", + "The patient developed anuria two days before admission.", + "The lactate concentration of the patient was 4.27 mmol/L.", + "The arterial pH was 7.31.", + "The patient did not meet the previously established definition for lactic acidosis.", + "The patient taking Met fulfilled the criteria for the diagnosis of lactic acidosis because the lactate concentration was > 4 mmol/L.", + "The patient was alert and appeared well.", + "The patient's blood glucose was 129 mg/dL.", + "The patient was not in the insulin-dependent state characteristic of euglycemic diabetic ketoacidosis.", + "The patient did not present with the physical symptoms of ketosis.", + "Computed tomography showed slight cortical atrophy in the bilateral kidneys.", + "No kidney stone or hydronephrosis was observed.", + "Bilateral hydronephrosis and nephrolithiasis were excluded based on the CT scan data.", + "The ratio of urea nitrogen to creatinine was < 20.", + "The patient was presumptively diagnosed with acute tubular necrosis with metabolic acidosis.", + "The anion-gap was 23.5 mmol/L.", + "The proximal tubular cells were diffusely enlarged with vacuolar degeneration.", + "All immunofluorescence results were negative.", + "No obvious abnormal findings were observed by electron microscopy.", + "The diagnosis of acute tubular necrosis was confirmed.", + "Intravenous hydration therapy was started.", + "Hemodialysis was introduced to remove Met.", + "Hemodialysis was performed with a polysulfone dialyzer.", + "The eGFR on day 0 was 5.1 mL/min/1.73 m2.", + "The patient resumed urination on day 2.", + "Anuria was recovered after the third session of hemodialysis.", + "The serum creatinine level on day 11 was 1.78 mg/dL.", + "The patient was discharged 13 days after hospitalization.", + "The Met concentration on day 3 was 8.95 µg/mL.", + "The Met concentration on day 5 was 2.58 µg/mL.", + "The Met concentration on day 7 was 0.16 µg/mL.", + "The one-compartment model pharmacokinetic analysis yielded an observed ke of 0.04 hours−1.", + "The calculated t1/2 (day 3–7) was 16.5 hours." + ], + "summary": "A 60-year-old Japanese man with type II diabetes, who was taking metformin (500 mg three times a day) along with several other medications, visited the emergency department with dizziness, malaise, and oliguria. The initial laboratory test results showed elevated levels of serum creatinine and blood urea nitrogen, although his renal function was normal approximately 2 weeks earlier. His lactate level was raised (4.27 mmol/L), and he was diagnosed with lactic acidosis. Considering the low creatinine clearance and elevated urinary albumin/serum creatinine ratio, urinary N-acetyl-β-D-glucosaminidase level, and β2-microglobulin level, the patient was further diagnosed with AKI (in other words, acute tubular necrosis). A renal biopsy performed on day 3 after admission revealed renal tubular epithelium necrosis, supporting this diagnosis. The patient underwent intermittent hemodialysis until he was discharged on day 13. The metformin concentrations on days 3, 5, and 7 were 8.95, 2.58, and 0.16 μg/mL, respectively, which is significantly higher than the maximal steady-state concentration of metformin at the recommended dosage (approximately 1 μg/mL). The calculated pharmacokinetic parameters of metformin suggested poor renal excretion and a low distribution volume at higher metformin levels. Other possible acute kidney injury-causing factors included dehydration, alcohol consumption, and the use of an angiotensin receptor blocker or SGLT2 inhibitor.", + "summary_subclaims": [ + "The patient is a 60-year-old Japanese man.", + "The patient has type II diabetes.", + "The patient was taking metformin (500 mg three times a day).", + "The patient visited the emergency department with dizziness, malaise, and oliguria.", + "The initial laboratory test results showed elevated levels of serum creatinine and blood urea nitrogen.", + "The patient's lactate level was 4.27 mmol/L.", + "The patient was diagnosed with lactic acidosis.", + "The patient was diagnosed with AKI, in other words, acute tubular necrosis.", + "A renal biopsy performed on day 3 after admission revealed renal tubular epithelium necrosis.", + "The patient underwent intermittent hemodialysis until he was discharged on day 13.", + "The metformin concentration on day 3 was 8.95 μg/mL.", + "The metformin concentration on day 5 was 2.58 μg/mL.", + "The metformin concentration on day 7 was 0.16 μg/mL.", + "The maximal steady-state concentration of metformin at the recommended dosage is approximately 1 μg/mL.", + "The calculated pharmacokinetic parameters of metformin suggested poor renal excretion.", + "Other possible acute kidney injury-causing factors included dehydration, alcohol consumption, and the use of an angiotensin receptor blocker or SGLT2 inhibitor." + ] + }, + { + "id": "multiclinsum_test_682_en.txt", + "fulltext": "A 61-year-old obese Caucasian female with a previous history of bipolar 1 disorder and hypothyroidism, presented for an out-patient psychiatric follow-up review accompanied by her Community Psychiatry Nurse. She was found to have pressured speech, elated mood, increased energy, and very poor personal hygiene. She was disheveled, unkempt, wearing dirty clothes, and was foul smelling. She was very agitated, and was verbally and physically abusive to staff. She had no insight, and refused any form of treatment. She was diagnosed with having a manic relapse secondary to non-adherence to medication, and was involuntarily admitted to the in-patient psychiatric ward. Complete blood count, electrolytes, glucose, liver function, and lipid profile were all within normal limits. Thyroid stimulating hormone was slightly elevated, although T4 was within normal limits. Vitamin B12 was on the low end of normal. She was re-started on her previous psychiatric medication, namely divalproex and clonazepam.\nThe following day she was adamant about having to go feed her cats and dogs, and eventually gave permission for a Community Mental Health Nurse enter her house to attend to her pets. Upon entering the house, it was found to be in complete disarray. The house was crammed with filthy clothes, garbage, dirty dishes, and rotting food. There was no kitchen sink in sight, and it looked as if some dishes were being cleaned in the toilet (see Figures and\n). Any clear space of floor was strewn with cat and dog feces. An unbearable stench emanated from the entire two-story home. Upon questioning the patient regarding the state of her home and personal hygiene, the patient had no insight into any problems. At this time, a diagnosis of Diogenes syndrome was suspected.\nDiagnosis of DS can be difficult as no one constellation of symptoms has been established. Hoarding, which can occur in DS, can also be found in many psychiatric conditions such as obsessive-compulsive disorder (OCD), schizophrenia, dementia, and others\n. The act of accumulation in DS is more likely ego-syntonic however, in contrast to the anxiety and intrusive thoughts that accompany collection in OCD\n. DS can be distinguished from personality disorders in that the personality in DS deteriorates, while the true personality disorder does not\n. Self-neglect can also be a part of dementia, schizophrenia, OCD, and affective disorders\n. Frontal lobe dementia tends to occur approximately 10 years prior to the typical age that DS patients are affected though\n. A diagnosis of schizophrenia can include delusions, hallucinations, and disorganized speech\n, which are not classical characteristics of DS. Clearer delineations between disorders need to exist however. An alterative suggestion was that DS “may be a final common pathway of different psychiatric disorders”\n.\nManagement of DS can be difficult, as patients often deny that there is a problem, may refuse any help, and can present late to medical attention\n, often in crisis. Ethical and legal issues can then arise, such as finding a balance between autonomy and beneficence\n. For example, a patient’s notion of self-neglect can be quite different than the view of their healthcare provider\n. Public Health issues may also arise concerning the patient’s housing. Fire, mould, and biological material can pollute the surrounding environment, so the health of nearby residents needs to be considered.\nEstablishing good rapport is vital in order to decrease the patient’s resistance to aid. A physical exam should be completed. Blood tests may include potassium, calcium, vitamin B12, iron, thyroid stimulating hormone, folate, and albumin\n. Functional inquiries and cognitive testing may be useful. Treatment usually begins by looking at any other possible psychiatric issues such as mania or psychosis. Risperidone has been suggested for use in DS even when there are no underlying psychotic features\n. Other pharmaceuticals that may be of benefit include zolpidem for sleep, paroxetine for hoarding, and sodium valproate or quetiapine for secondary bipolar disorders\n. Flexible outpatient treatment through community care providers is preferable if there is little risk to the patient or to others\n. This can include counseling and cleaning services, and individualized case management\n. The mental health act can be used if difficulties are experienced in managing higher-risk patients. If management is not conducted in a sensitive manner, patients will simply return to the same living condition, with much more resistance to support and follow-up.\nThe prognosis of affected individuals depends on their capability of re-integrating into society, and often relies on the patients making small changes away from unhealthy living conditions\n. Other poor prognostic factors include poor physical health, which may already be advanced due to neglect, and early age at onset.\nAs time progressed as an in-patient, the patient’s mood settled, although she remained guarded, with little insight into her self-care. The patient required persistent and gentle pressure in order to even start thinking about de-cluttering and improving her personal hygiene. She was eventually persuaded to allow a company to help her clean her home, at a cost of $8,073. The patient was present at the clean up. The sink was eventually found under a large pile of debris. The patient is now living at home, and receiving close follow-up with her Community Psychiatry Nurse and Psychiatrist. It remains to be seen whether these interventions will make any long-term impact to her living condition and health.", + "fulltext_subclaims": [ + "The patient was a 61-year-old obese Caucasian female.", + "She had a previous history of bipolar 1 disorder.", + "She had a previous history of hypothyroidism.", + "She presented for an out-patient psychiatric follow-up review.", + "She was accompanied by her Community Psychiatry Nurse.", + "She was found to have pressured speech.", + "She was found to have an elated mood.", + "She was found to have increased energy.", + "She had very poor personal hygiene.", + "She was disheveled and unkempt.", + "She was wearing dirty clothes.", + "She was foul smelling.", + "She was very agitated.", + "She was verbally abusive to staff.", + "She was physically abusive to staff.", + "She had no insight.", + "She refused any form of treatment.", + "She was diagnosed with a manic relapse.", + "The manic relapse was secondary to non-adherence to medication.", + "She was involuntarily admitted to the in-patient psychiatric ward.", + "Complete blood count was within normal limits.", + "Electrolytes were within normal limits.", + "Glucose was within normal limits.", + "Liver function was within normal limits.", + "Lipid profile was within normal limits.", + "Thyroid stimulating hormone was slightly elevated.", + "T4 was within normal limits.", + "Vitamin B12 was on the low end of normal.", + "She was re-started on her previous psychiatric medication.", + "The previous psychiatric medication included divalproex.", + "The previous psychiatric medication included clonazepam.", + "The following day she was adamant about having to go feed her cats and dogs.", + "She gave permission for a Community Mental Health Nurse to enter her house to attend to her pets.", + "Upon entering the house, it was found to be in complete disarray.", + "The house was crammed with filthy clothes.", + "The house was crammed with garbage.", + "The house was crammed with dirty dishes.", + "The house was crammed with rotting food.", + "There was no kitchen sink in sight.", + "It looked as if some dishes were being cleaned in the toilet.", + "Any clear space of floor was strewn with cat and dog feces.", + "An unbearable stench emanated from the entire two-story home.", + "Upon questioning the patient, she had no insight into any problems.", + "At this time, a diagnosis of Diogenes syndrome was suspected.", + "Diagnosis of Diogenes syndrome can be difficult.", + "Hoarding can occur in Diogenes syndrome.", + "Hoarding can also be found in many psychiatric conditions.", + "The act of accumulation in Diogenes syndrome is more likely ego-syntonic.", + "DS can be distinguished from personality disorders.", + "The personality in Diogenes syndrome deteriorates.", + "The true personality disorder does not deteriorate.", + "Self-neglect can also be a part of dementia.", + "Self-neglect can also be a part of schizophrenia.", + "Self-neglect can also be a part of obsessive-compulsive disorder.", + "Self-neglect can also be a part of affective disorders.", + "Frontal lobe dementia tends to occur approximately 10 years prior to the typical age that DS patients are affected.", + "A diagnosis of schizophrenia can include delusions.", + "A diagnosis of schizophrenia can include hallucinations.", + "A diagnosis of schizophrenia can include disorganized speech.", + "Delusions, hallucinations, and disorganized speech are not classical characteristics of Diogenes syndrome.", + "An alternative suggestion was that Diogenes syndrome may be a final common pathway of different psychiatric disorders.", + "Management of Diogenes syndrome can be difficult.", + "Patients often deny that there is a problem.", + "Patients may refuse any help.", + "Patients can present late to medical attention.", + "Ethical and legal issues can arise.", + "A patient’s notion of self-neglect can be quite different than the view of their healthcare provider.", + "Public Health issues may also arise concerning the patient’s housing.", + "Fire, mould, and biological material can pollute the surrounding environment.", + "The health of nearby residents needs to be considered.", + "Establishing good rapport is vital.", + "A physical exam should be completed.", + "Blood tests may include potassium.", + "Blood tests may include calcium.", + "Blood tests may include vitamin B12.", + "Blood tests may include iron.", + "Blood tests may include thyroid stimulating hormone.", + "Blood tests may include folate.", + "Blood tests may include albumin.", + "Functional inquiries and cognitive testing may be useful.", + "Treatment usually begins by looking at any other possible psychiatric issues.", + "Risperidone has been suggested for use in Diogenes syndrome.", + "Risperidone may be used even when there are no underlying psychotic features.", + "Zolpidem may be of benefit for sleep.", + "Paroxetine may be of benefit for hoarding.", + "Sodium valproate may be of benefit for secondary bipolar disorders.", + "Quetiapine may be of benefit for secondary bipolar disorders.", + "Flexible outpatient treatment through community care providers is preferable if there is little risk to the patient or to others.", + "This can include counseling.", + "This can include cleaning services.", + "This can include individualized case management.", + "The mental health act can be used if difficulties are experienced in managing higher-risk patients.", + "If management is not conducted in a sensitive manner, patients will simply return to the same living condition.", + "Patients will return with much more resistance to support and follow-up.", + "The prognosis of affected individuals depends on their capability of re-integrating into society.", + "The prognosis often relies on the patients making small changes away from unhealthy living conditions.", + "Other poor prognostic factors include poor physical health.", + "Poor physical health may already be advanced due to neglect.", + "Other poor prognostic factors include early age at onset.", + "As time progressed as an in-patient, the patient’s mood settled.", + "She remained guarded.", + "She had little insight into her self-care.", + "She required persistent and gentle pressure to start thinking about de-cluttering.", + "She required persistent and gentle pressure to start thinking about improving her personal hygiene.", + "She was eventually persuaded to allow a company to help her clean her home.", + "The clean up cost $8,073.", + "The patient was present at the clean up.", + "The sink was eventually found under a large pile of debris.", + "The patient is now living at home.", + "She is receiving close follow-up with her Community Psychiatry Nurse.", + "She is receiving close follow-up with her Psychiatrist.", + "It remains to be seen whether these interventions will make any long-term impact to her living condition.", + "It remains to be seen whether these interventions will make any long-term impact to her health." + ], + "summary": "61-year Caucasian female known with bipolar 1 disorder presented with manic symptoms. She was very unkempt and foul smelling. After being admitted involuntarily, she requested that someone go to her home to feed her pets. Her house was filled with garbage, rotting food, and animal feces. She had no insight into any personal hygiene or public health problems.", + "summary_subclaims": [ + "The patient is a 61-year Caucasian female.", + "She has bipolar 1 disorder.", + "She presented with manic symptoms.", + "She was very unkempt and foul smelling.", + "She was admitted involuntarily.", + "She requested that someone go to her home to feed her pets.", + "Her house was filled with garbage, rotting food, and animal feces.", + "She had no insight into any personal hygiene or public health problems." + ] + }, + { + "id": "multiclinsum_test_1904_en.txt", + "fulltext": "The present case is a 71-year-old male patient who had a laparoscopic radical cystoprostatectomy and ileal conduit for muscle-invasive bladder cancer (pathological stage T4aN2Mx). During the perioperative period, a foley catheter was used as traction and as a drain through the urethral route, and the catheter was removed on the 4th postoperative day. The patient’s past medical history does not reveal chronic disease, including diabetes. Also, his renal function test and other laboratory parameters were within normal limits. The preoperative clinical lymph node status was N0. The intraoperative blood loss was minimal, and no blood transfusion was needed. Enoxapirin was used for one month postoperatively. Two weeks postoperatively, the patient presented with yellow-white discharge from the meatus and bruising in the glans around the meatus . Physical examination revealed glandular necrosis. Appropriate antimicrobial therapy (Meropenem + Teicoplanin + clindamycin ) was initiated after the patient’s admission. Initial laboratory investigation revealed an elevated white blood cell count (12,420ng/dl), and CRP (19.9), while other parameters were within normal limits.\nThe urethral discharge culture showed an E.coli, Klebsiella pneumonia, and Enterococcus faecium. Colistin and Tigecycline antimicrobial therapy were started after infectious disease consultation.\nSurgical exploration was planned for the patient, as there was no improvement on the 9th day of the antibiotic therapy. During the procedure, it was observed that the necrosis was not limited to the glans. The necrosis had spread to the entire penile urethra and corpus spongiosum, and an excision of approximately 14 cm of corpus spongiosum was performed .\nThe postoperative period was uneventful, and the patient was discharged on the 6th postoperative day . The pathology findings reported no malignancy and showed dıffuse hemorrhage and necrosıs of the urethra and extendıng to the surrounding tıssues. Glans necrosıs, ulceratıon, hemorrhage and chronıc ınflammatıon were also reported.", + "fulltext_subclaims": [ + "The patient is a 71-year-old male.", + "The patient had a laparoscopic radical cystoprostatectomy and ileal conduit for muscle-invasive bladder cancer.", + "The pathological stage was T4aN2Mx.", + "A foley catheter was used as traction and as a drain through the urethral route.", + "The catheter was removed on the 4th postoperative day.", + "The patient’s past medical history does not reveal chronic disease, including diabetes.", + "The preoperative clinical lymph node status was N0.", + "Intraoperative blood loss was minimal.", + "No blood transfusion was needed.", + "Enoxapirin was used for one month postoperatively.", + "Two weeks postoperatively, the patient presented with yellow-white discharge from the meatus.", + "Physical examination revealed glandular necrosis.", + "Appropriate antimicrobial therapy (Meropenem + Teicoplanin + clindamycin) was initiated after the patient’s admission.", + "Initial laboratory investigation revealed an elevated white blood cell count (12,420ng/dl).", + "The urethral discharge culture showed E.coli, Klebsiella pneumonia, and Enterococcus faecium.", + "Colistin and Tigecycline antimicrobial therapy were started after infectious disease consultation.", + "Surgical exploration was planned for the patient.", + "During the procedure, it was observed that the necrosis had spread to the entire penile urethra and corpus spongiosum.", + "An excision of approximately 14 cm of corpus spongiosum was performed.", + "The postoperative period was uneventful.", + "The patient was discharged on the 6th postoperative day.", + "The pathology findings reported no malignancy.", + "The pathology findings showed diffuse hemorrhage and necrosis of the urethra and extending to the surrounding tissues.", + "Glans necrosis, ulceration, hemorrhage and chronic inflammation were also reported." + ], + "summary": "We report a rare case presenting extensive penile glans and corpus spongiosum necrosis following catheter traction in a 71-year-old male patient who had a laparoscopic radical cystoprostatectomy for muscle-invasive bladder cancer. The patient has no preexisting diabetes mellitus or chronic renal failure. The case was successfully managed with penile preservation. During the procedure, it was observed that the necrosis was not limited to the glans. The necrosis had spread to the entire penile urethra and corpus spongiosum, and an excision of approximately 14 cm of corpus spongiosum was performed.", + "summary_subclaims": [ + "A 71-year-old male patient had a laparoscopic radical cystoprostatectomy for muscle-invasive bladder cancer.", + "The patient had extensive penile glans and corpus spongiosum necrosis following catheter traction.", + "The patient has no preexisting diabetes mellitus.", + "The patient has no chronic renal failure.", + "The case was successfully managed with penile preservation.", + "The necrosis was not limited to the glans.", + "The necrosis had spread to the entire penile urethra and corpus spongiosum.", + "An excision of approximately 14 cm of corpus spongiosum was performed." + ] + }, + { + "id": "multiclinsum_test_419_en.txt", + "fulltext": "A 65-year-old woman with a 5-year history of clinical stage IIA (T2N0M0) invasive ductal carcinoma of the left breast was hospitalized for worsening shortness of breath, hemoptysis, and cough since 2 months. Her breast carcinoma was 32 mm in diameter at diagnosis, with a histologic grade of 3 and nuclear grade of 3. Immunostaining for the estrogen receptor and progesterone receptor revealed negativity for both, but the tumor cells were positive for HER2. The patient had received neoadjuvant chemotherapy with four cycles of epirubicin and cyclophosphamide, followed by four cycles of trastuzumab and paclitaxel. A left mastectomy had been performed, and the surgical specimen showed no residual cancer. After the operation, four cycles of trastuzumab had been administered as adjuvant chemotherapy; however, trastuzumab had been discontinued because of heart failure. Echocardiography showed diffuse and moderate impairment of left ventricular contraction and a decrease in ejection fraction from 65.8 % to 36 %. Seven months after stopping trastuzumab administration, a repeat echocardiography revealed that her ejection fraction had recovered. Since then, she had been followed-up without treatment for breast carcinoma until this readmission.\nOn admission, the patient showed normal auscultation findings. A chest radiograph showed faint infiltrates at the base of both the lungs. Arterial blood gas analysis using room air indicated minimal hypoxemia: pH, 7.42; PaCO2, 42 mmHg; and PaO2, 78 mmHg. D-dimer levels were slightly increased to 1.2 μg/mL (normal, <1.0 μg/mL). Serum levels of carcinoembryonic antigen and HER2 were elevated to 57.0 μg/L (normal, 0.8–4.8 μg/L) and 64.9 ng/mL (normal, <15.2 ng/mL), respectively. Contrast-enhanced computed tomography (CT) scans revealed peripheral consolidation with ground-glass opacity in both the lower lobes and a heterogeneous mediastinal mass . 18F-fluorodeoxyglucose (FDG)-positron emission tomography demonstrated increased FDG uptake in the peripheral consolidation and the mass. Echocardiography revealed normal contractions without any finding suggestive of pulmonary hypertension. Because transbronchial lung biopsy did not lead to any diagnosis, video-assisted thoracoscopic surgery (VATS) lung biopsy was performed. The surgical specimens of the peripheral area of the left lower lobe and the mediastinal mass revealed tumor cell embolism, intimal fibrocellular proliferation of small arteries, fibrin thrombi, recanalization, and infarction in the left lower lobe, as well as metastasis to the mediastinal pleura . Immunohistochemical staining of tumor cells revealed positivity for mammaglobin, gross cystic disease fluid protein 15, HER2 (3+), and vascular endothelial growth factor. Accordingly, a diagnosis of recurrent breast cancer with PTTM was made.\nRetreatment with trastuzumab therapy rapidly improved the symptoms and CT findings of peripheral consolidation and the mass, resulting in partial remission . After four cycles of trastuzumab therapy, it was stopped owing to heart failure. The patient visited another hospital and is alive more than 2 years after the diagnosis of PTTM.", + "fulltext_subclaims": [ + "The patient is a 65-year-old woman.", + "She has a 5-year history of clinical stage IIA (T2N0M0) invasive ductal carcinoma of the left breast.", + "She was hospitalized for worsening shortness of breath, hemoptysis, and cough since 2 months.", + "Her breast carcinoma was 32 mm in diameter at diagnosis.", + "The tumor had a histologic grade of 3 and nuclear grade of 3.", + "Immunostaining for the estrogen receptor and progesterone receptor revealed negativity for both.", + "The tumor cells were positive for HER2.", + "She had received neoadjuvant chemotherapy with four cycles of epirubicin and cyclophosphamide.", + "She had received four cycles of trastuzumab and paclitaxel.", + "A left mastectomy had been performed.", + "The surgical specimen showed no residual cancer.", + "After the operation, four cycles of trastuzumab had been administered as adjuvant chemotherapy.", + "Trastuzumab had been discontinued because of heart failure.", + "Echocardiography showed diffuse and moderate impairment of left ventricular contraction.", + "Ejection fraction decreased from 65.8 % to 36 %.", + "Seven months after stopping trastuzumab administration, a repeat echocardiography revealed that her ejection fraction had recovered.", + "She had been followed-up without treatment for breast carcinoma until this readmission.", + "On admission, the patient showed normal auscultation findings.", + "A chest radiograph showed faint infiltrates at the base of both the lungs.", + "Arterial blood gas analysis using room air indicated minimal hypoxemia: pH, 7.42; PaCO2, 42 mmHg; and PaO2, 78 mmHg.", + "D-dimer levels were slightly increased to 1.2 μg/mL.", + "Serum levels of carcinoembryonic antigen were elevated to 57.0 μg/L.", + "Serum levels of HER2 were elevated to 64.9 ng/mL.", + "Contrast-enhanced computed tomography scans revealed peripheral consolidation with ground-glass opacity in both the lower lobes.", + "Contrast-enhanced computed tomography scans revealed a heterogeneous mediastinal mass.", + "18F-fluorodeoxyglucose (FDG)-positron emission tomography demonstrated increased FDG uptake in the peripheral consolidation.", + "18F-fluorodeoxyglucose (FDG)-positron emission tomography demonstrated increased FDG uptake in the mass.", + "Echocardiography revealed normal contractions without any finding suggestive of pulmonary hypertension.", + "Transbronchial lung biopsy did not lead to any diagnosis.", + "Video-assisted thoracoscopic surgery (VATS) lung biopsy was performed.", + "The surgical specimens revealed tumor cell embolism.", + "The surgical specimens revealed intimal fibrocellular proliferation of small arteries.", + "The surgical specimens revealed fibrin thrombi.", + "The surgical specimens revealed recanalization.", + "The surgical specimens revealed infarction in the left lower lobe.", + "The surgical specimens revealed metastasis to the mediastinal pleura.", + "Immunohistochemical staining of tumor cells revealed positivity for mammaglobin.", + "Immunohistochemical staining of tumor cells revealed positivity for gross cystic disease fluid protein 15.", + "Immunohistochemical staining of tumor cells revealed positivity for HER2 (3+).", + "Immunohistochemical staining of tumor cells revealed positivity for vascular endothelial growth factor.", + "A diagnosis of recurrent breast cancer with PTTM was made.", + "Retreatment with trastuzumab therapy rapidly improved the symptoms.", + "Retreatment with trastuzumab therapy rapidly improved the CT findings of peripheral consolidation.", + "Retreatment with trastuzumab therapy rapidly improved the CT findings of the mass.", + "After four cycles of trastuzumab therapy, it was stopped owing to heart failure.", + "The patient is alive more than 2 years after the diagnosis of PTTM." + ], + "summary": "A 65-year-old woman with a 5-year history of clinical stage IIA (T2N0M0) invasive ductal carcinoma of the left breast was hospitalized for worsening shortness of breath, hemoptysis, and cough since 2 months. She had previously received neoadjuvant chemotherapy and left mastectomy. Because the cancer cells were positive for human epidermal growth factor receptor 2 (HER2), four cycles of trastuzumab had been administered as adjuvant chemotherapy. On admission, chest computed tomography (CT) showed peripheral consolidations in both the lower lobes and a mediastinal mass. Specimens obtained on video-assisted thoracoscopic surgical biopsy revealed tumor cell embolism, intimal fibrocellular proliferation of small arteries, fibrin thrombi, recanalization, and infarction in the left lower lobe, as well as metastasis to the mediastinal pleura. Immunohistochemical staining of the tumor cells revealed positivity for HER2, and a diagnosis of recurrent breast cancer with PTTM was made. Four cycles of trastuzumab resulted in rapid improvement of her symptoms and CT findings of peripheral consolidations and the mediastinal mass.", + "summary_subclaims": [ + "The patient is a 65-year-old woman.", + "She has a 5-year history of clinical stage IIA (T2N0M0) invasive ductal carcinoma of the left breast.", + "She was hospitalized for worsening shortness of breath, hemoptysis, and cough since 2 months.", + "She had previously received neoadjuvant chemotherapy.", + "She had a left mastectomy.", + "The cancer cells were positive for human epidermal growth factor receptor 2 (HER2).", + "Four cycles of trastuzumab had been administered as adjuvant chemotherapy.", + "Chest computed tomography showed peripheral consolidations in both the lower lobes.", + "Chest computed tomography showed a mediastinal mass.", + "Specimens obtained on video-assisted thoracoscopic surgical biopsy revealed tumor cell embolism.", + "Specimens revealed intimal fibrocellular proliferation of small arteries.", + "Specimens revealed fibrin thrombi.", + "Specimens revealed recanalization.", + "Specimens revealed infarction in the left lower lobe.", + "Specimens revealed metastasis to the mediastinal pleura.", + "Immunohistochemical staining of the tumor cells revealed positivity for HER2.", + "A diagnosis of recurrent breast cancer with PTTM was made.", + "Four cycles of trastuzumab resulted in rapid improvement of her symptoms.", + "CT findings showed improvement of peripheral consolidations.", + "CT findings showed improvement of the mediastinal mass." + ] + }, + { + "id": "multiclinsum_test_2389_en.txt", + "fulltext": "The patient was a 23-year-old woman who was 167.5 cm tall, weighed 62.9 kg, and had a body mass index of 22.4 kg/m2. The patient had no relevant medical history and had not been vaccinated against COVID-19. In early September 2021, she developed a fever with general malaise and tested positive for severe acute respiratory syndrome coronavirus 2 (SARS-CoV-2) infection on polymerase chain reaction (PCR). At the time, the SARS-CoV-2 Delta (B.1.617.2) variant was prevalent in Japan.\nAs the patient had signs of pneumonia, an intravenous infusion of 200 mg of remdesivir was administered on day 8 of COVID-19, followed by 100 mg of intravenous remdesivir once daily for the next 3 days. On day 9, the patient suddenly developed pain in the right hip, accompanied by general pain. On examination, she had tenderness in Scarpa’s triangle without redness, heat, or swelling around the hip. The range of hip motion was limited by pain on flexion (right 80°/left 120°).\nBlood tests on day 15 after COVID-19 onset showed an elevated C-reactive protein (CRP) level (14.63 mg/dL; reference: 0.00–0.23 mg/dL), and an elevated white blood cell (WBC) count (18.0 × 103 cells/μL; reference: 3.90 × 103–9.80×103 cells/μL) but were negative for rheumatoid factor, antinuclear antibodies, human leukocyte antigen-B27, hepatitis, and human immunodeficiency virus (HIV). Urine culture was negative; however, blood culture revealed β-lactamase-producing Staphylococcus aureus infection. An expanded low-density area was observed in the capsule of the right hip joint in the contrast-enhanced computed tomography (CT) on day 21 after the disease onset, and arthrocentesis was performed on the same day. The joint fluid was cloudy and yellowish-white in color . Culture of the joint fluid was negative. However, the possibility of pyogenic arthritis was considered because β lactamase-producing S. aureus had been detected on the blood culture. Therefore, cefazolin was administered intravenously on day 23 after COVID-19 onset.\nHowever, the patient’s right hip pain persisted without a change in the size of the low-density area of the right hip on CT. On day 36 after COVID-19 onset, after two negative SARS-CoV-2 PCR test results, contrast-enhanced magnetic resonance imaging (MRI) revealed restricted diffusion in the fluid reservoir of the right hip, suggesting abscess formation ( and ). Therefore, surgical treatment with curettage and irrigation was performed on day 53, 2 weeks after the negative PCR test, according to the hospital regulations .\nIntraoperative joint fluid culture and PCR test results for SARS-CoV-2 were negative. However, the cell count of the joint fluid was 20,800 cells/μL (neutrophil: 88%, lymphocyte: 2%, and monocyte: 10%) and the specific gravity was 1.040. Moreover, the protein and sugar levels were 8.0 g/dL and 52 mg/dL, respectively. The Synovasure a-Defensin Detection Kit (Zimmer Biomet, Warsaw, IA, USA) showed positive results, and histopathology of synovial tissue revealed numerous neutrophils with segmental lobe nuclei ( and ).\nAfter surgery, the patient was treated with intravenous cefazolin, and the affected hip joint was continuously irrigated with 100 mg of amikacin sulfate dissolved in 1 L of saline daily for 11 days. Cultures of the drainage fluid during continuous irrigation were repeatedly negative. Oral antibiotics (1600 mg sulfamethoxazole-trimethoprim 1600/320 mg/day and rifampicin 450 mg/day) were initiated the day after intravenous antibiotic administration and continuous irrigation was completed.\nThe patient’s right hip pain improved, and she was discharged from the hospital on day 68 after COVID-19 onset. Rifampicin was discontinued 3 months postoperatively, whereas sulfamethoxazole-trimethoprim was discontinued 4 months postoperatively. Loxoprofen was administered from day 9 after COVID-19 onset until 1 month postoperatively, but no steroids were administered. Six months after surgery, the patient had no symptoms and a Harris hip score of 96. Radiography revealed no abnormalities , and MRI showed a marked reduction in the joint effusion of the right hip. Furthermore, no diffusion restriction was observed that would suggest an abscess ( and ). Blood tests revealed a normal CRP level and WBC count.", + "fulltext_subclaims": [ + "The patient was a 23-year-old woman.", + "The patient was 167.5 cm tall.", + "The patient weighed 62.9 kg.", + "The patient had a body mass index of 22.4 kg/m2.", + "The patient had no relevant medical history.", + "The patient had not been vaccinated against COVID-19.", + "In early September 2021, she developed a fever with general malaise.", + "She tested positive for SARS-CoV-2 infection on PCR.", + "The SARS-CoV-2 Delta variant was prevalent in Japan.", + "The patient had signs of pneumonia.", + "An intravenous infusion of 200 mg of remdesivir was administered on day 8 of COVID-19.", + "100 mg of intravenous remdesivir was administered once daily for the next 3 days.", + "On day 9, the patient suddenly developed pain in the right hip.", + "On examination, she had tenderness in Scarpa’s triangle.", + "The range of hip motion was limited by pain on flexion.", + "Blood tests on day 15 after COVID-19 onset showed an elevated C-reactive protein level.", + "Blood tests showed an elevated white blood cell count.", + "Blood culture revealed β-lactamase-producing Staphylococcus aureus infection.", + "An expanded low-density area was observed in the capsule of the right hip joint in contrast-enhanced CT.", + "Arthrocentesis was performed on day 21 after the disease onset.", + "The joint fluid was cloudy and yellowish-white in color.", + "Culture of the joint fluid was negative.", + "The possibility of pyogenic arthritis was considered.", + "Cefazolin was administered intravenously on day 23 after COVID-19 onset.", + "The patient’s right hip pain persisted.", + "Contrast-enhanced MRI revealed restricted diffusion in the fluid reservoir of the right hip.", + "Surgical treatment with curettage and irrigation was performed on day 53.", + "Intraoperative joint fluid culture was negative.", + "The cell count of the joint fluid was 20,800 cells/μL.", + "The Synovasure a-Defensin Detection Kit showed positive results.", + "Histopathology of synovial tissue revealed numerous neutrophils with segmental lobe nuclei.", + "The patient was treated with intravenous cefazolin.", + "The affected hip joint was continuously irrigated with 100 mg of amikacin sulfate dissolved in 1 L of saline daily.", + "Cultures of the drainage fluid during continuous irrigation were repeatedly negative.", + "Oral antibiotics were initiated the day after intravenous antibiotic administration.", + "The patient’s right hip pain improved.", + "She was discharged from the hospital on day 68 after COVID-19 onset.", + "Rifampicin was discontinued 3 months postoperatively.", + "Sulfamethoxazole-trimethoprim was discontinued 4 months postoperatively.", + "Loxoprofen was administered from day 9 after COVID-19 onset until 1 month postoperatively.", + "No steroids were administered.", + "Six months after surgery, the patient had no symptoms.", + "The Harris hip score was 96.", + "Radiography revealed no abnormalities.", + "MRI showed a marked reduction in the joint effusion of the right hip.", + "No diffusion restriction was observed that would suggest an abscess.", + "Blood tests revealed a normal CRP level.", + "Blood tests revealed a normal WBC count." + ], + "summary": "We treated a young woman with secondary pyogenic hip arthritis that started after COVID-19. The patient was a 23-year-old woman who developed acute pain in the right hip 9 days after being diagnosed with COVID-19. Blood cultures revealed methicillin-sensitive Staphylococcus aureus and contrast-enhanced computed tomography revealed joint effusion in the right hip. Although the joint fluid culture results were negative, we suspected pyogenic arthritis of the hip joint and performed curettage and continuous irrigation of the right hip joint. Intraoperative histopathological examination of the synovial membrane revealed numerous neutrophils with segmental nuclei, consistent with a diagnosis of pyogenic arthritis.", + "summary_subclaims": [ + "The patient was a 23-year-old woman.", + "She developed acute pain in the right hip 9 days after being diagnosed with COVID-19.", + "Blood cultures revealed methicillin-sensitive Staphylococcus aureus.", + "Contrast-enhanced computed tomography revealed joint effusion in the right hip.", + "The joint fluid culture results were negative.", + "We suspected pyogenic arthritis of the hip joint.", + "We performed curettage and continuous irrigation of the right hip joint.", + "Intraoperative histopathological examination of the synovial membrane revealed numerous neutrophils with segmental nuclei.", + "The histopathological findings were consistent with a diagnosis of pyogenic arthritis." + ] + }, + { + "id": "multiclinsum_test_118_en.txt", + "fulltext": "An 18-year-old man was referred for painful bilateral testicular tumors confirmed with scrotal ultrasonography. MRI revealed a 2.5 cm tumor and a 3.0 cm tumor in the rete testis regions of the right and left testicles, respectively . CBC, LH (4.9 mIU/mL, normal 1.5–9.3 mIU/mL), FSH (5.1 mIU/mL, normal 1.6–8.0 mIU/mL), and total testosterone (398 ng/dL, normal 249–836 ng/dL) were normal. Tumor marker beta-HCG, AFP, and LDH were also normal. Both tumors subjectively progressed in size during the time between initial evaluation and surgery. Bilateral partial orchiectomies were attempted . The right was converted to a radical orchiectomy with prosthesis due to intraoperative concerns regarding testis viability. A partial orchiectomy was successfully completed on the left. Intraoperative frozen sections were not conclusive for germ cell, Leydig cell, or another histology. Pathologic evaluation of both tumors revealed the proliferation of tumor cells throughout the testicular parenchyma and rete testis, with nodules ranging from <1 to 10 mm, a low proliferation index (Ki67 positive in 1% of cells) and negative p53. No features of malignancy such as necrosis, mitotic figures, or pleomorphism were present . A presumptive diagnosis of Leydig cell tumors vs TARTs was suggested.\nCT scans of the abdomen and pelvis revealed a soft tissue density measuring 2.1 × 1.7 cm in the left para-aortic region . Also noted were slightly enlarged inter-aortocaval nodes and a small left adrenal nodule. An image-guided biopsy of the para-aortic mass was nondiagnostic.\nA postoperative endocrine evaluation revealed markedly elevated ACTH levels (4322 pg/mL) yet normal cortisol levels. The patient’s clinical and radiographic findings, testis pathology, and elevated ACTH level, all supported a diagnosis of NCAH and the presence of TARTs. The postoperative endocrine evaluation also revealed an LH level of 21.5 mIU/mL, FSH of 22.9 mIU/mL, and a low testosterone level (81 ng/dL). Borderline adrenal insufficiency and moderate hypogonadism were effectively managed with hydrocortisone and testosterone supplementation. Larger than average doses of hydrocortisone were necessary to maintain the ACTH at a desired level (under 100 pg/mL).\nFollow-up scrotal U/S and CT scans 2 years post-surgery revealed a right testicular prosthesis, a partial left testicle containing no new masses, and a stable para-aortic soft tissue mass .", + "fulltext_subclaims": [ + "An 18-year-old man was referred for painful bilateral testicular tumors confirmed with scrotal ultrasonography.", + "MRI revealed a 2.5 cm tumor in the rete testis region of the right testicle.", + "MRI revealed a 3.0 cm tumor in the rete testis region of the left testicle.", + "CBC, LH (4.9 mIU/mL, normal 1.5–9.3 mIU/mL), FSH (5.1 mIU/mL, normal 1.6–8.0 mIU/mL), and total testosterone (398 ng/dL, normal 249–836 ng/dL) were normal.", + "Tumor marker beta-HCG, AFP, and LDH were also normal.", + "Both tumors subjectively progressed in size during the time between initial evaluation and surgery.", + "Bilateral partial orchiectomies were attempted.", + "The right was converted to a radical orchiectomy with prosthesis due to intraoperative concerns regarding testis viability.", + "A partial orchiectomy was successfully completed on the left.", + "Intraoperative frozen sections were not conclusive for germ cell, Leydig cell, or another histology.", + "Pathologic evaluation of both tumors revealed the proliferation of tumor cells throughout the testicular parenchyma and rete testis.", + "Nodules ranged from <1 to 10 mm.", + "The proliferation index (Ki67 positive in 1% of cells) was low.", + "p53 was negative.", + "No features of malignancy such as necrosis, mitotic figures, or pleomorphism were present.", + "A presumptive diagnosis of Leydig cell tumors vs TARTs was suggested.", + "CT scans of the abdomen and pelvis revealed a soft tissue density measuring 2.1 × 1.7 cm in the left para-aortic region.", + "Slightly enlarged inter-aortocaval nodes were noted.", + "A small left adrenal nodule was noted.", + "An image-guided biopsy of the para-aortic mass was nondiagnostic.", + "A postoperative endocrine evaluation revealed markedly elevated ACTH levels (4322 pg/mL) yet normal cortisol levels.", + "The patient’s clinical and radiographic findings, testis pathology, and elevated ACTH level all supported a diagnosis of NCAH and the presence of TARTs.", + "The postoperative endocrine evaluation also revealed an LH level of 21.5 mIU/mL.", + "The postoperative endocrine evaluation also revealed an FSH level of 22.9 mIU/mL.", + "The postoperative endocrine evaluation also revealed a low testosterone level (81 ng/dL).", + "Borderline adrenal insufficiency and moderate hypogonadism were effectively managed with hydrocortisone and testosterone supplementation.", + "Larger than average doses of hydrocortisone were necessary to maintain the ACTH at a desired level (under 100 pg/mL).", + "Follow-up scrotal U/S and CT scans 2 years post-surgery revealed a right testicular prosthesis.", + "Follow-up scrotal U/S and CT scans 2 years post-surgery revealed a partial left testicle containing no new masses.", + "Follow-up scrotal U/S and CT scans 2 years post-surgery revealed a stable para-aortic soft tissue mass." + ], + "summary": "We present a case of an 18-year-old male undergoing attempted bilateral partial orchiectomies for suspected germ cell tumors. Tumor pathology, laboratory results, radiographic studies, and post-surgical elevated adrenocorticotropic hormone levels supported the diagnosis of testicular adrenal rest tumors secondary to previously undiagnosed nonclassical congenital adrenal hyperplasia.", + "summary_subclaims": [ + "The patient is an 18-year-old male.", + "The patient underwent attempted bilateral partial orchiectomies.", + "The surgeries were for suspected germ cell tumors.", + "Tumor pathology supported the diagnosis of testicular adrenal rest tumors.", + "Laboratory results supported the diagnosis of testicular adrenal rest tumors.", + "Radiographic studies supported the diagnosis of testicular adrenal rest tumors.", + "Post-surgical elevated adrenocorticotropic hormone levels supported the diagnosis.", + "The tumors were secondary to previously undiagnosed nonclassical congenital adrenal hyperplasia." + ] + }, + { + "id": "multiclinsum_test_668_en.txt", + "fulltext": "A 47-year-old male patient presented with a red eye, scleral nodule, and increased intraocular pressure (IOP) in the left eye for 3 weeks after an eye injury from sawdust. At a regional hospital, he was treated as nodular scleritis and secondary ocular hypertension for 1 week with topical prednisolone acetate 1% every 2 h, nepafenac four times daily, timolol maleate 0.5% and brimonidine tartrate 0.1% twice daily, oral prednisolone 15 mg/day, and oral acetazolamide 250 mg twice daily. When the lesion did not improve, the patient was referred to a tertiary hospital. His best corrected visual acuity (BCVA) was 6/6 and 6/12 in OD and OS, respectively. Slit-lamp examination revealed a painless, slow-growing nodular lesion at the inferonasal area with marked injection of conjunctiva and mucopurulent discharge . There was a small infiltration of the adjacent peripheral cornea; otherwise, the anterior chamber, the lens, and fundus were unremarkable with an IOP of 20 mm Hg. The patient was diagnosed as infectious scleritis with scleral abscess and was admitted to hospital. Both topical and oral steroids were discontinued and a surgical drainage was performed. Yellow pus from the abscess was sent for microbial study including a potassium hydroxide wet mount, Calcofluor white staining, Gram staining, and bacterial and fungal cultures. The smears showed no organism and the culture did not grow any organism. The patient was initially treated as infectious scleritis with fortified cefazolin (33 mg/mL) and fortified gentamycin (14 mg/mL) every 2 h and oral ciprofloxacin 500 mg twice daily along with previous anti-glaucoma medications. Eight days after treatment, the sclera nodule resolved, and the cornea was clear with controlled IOP, so the patient was discharged and instructed to follow up at the previous regional hospital. Two weeks later, his vision got worse, so he went to the regional hospital. At that time, increased corneal haze and anterior chamber reaction with plasmoid aqueous and vitreous haze in the left eye were noticed. The patient received fortified cefazolin and fortified gentamycin hourly to the left eye as well as systemic therapy with intravenous vancomycin 500 mg/day and ceftazidime 1 g/day, before referral to a tertiary hospital.\nAt the second referral, BCVA were 6/6 and hand motion in OD and OS, respectively. Slit-lamp examination revealed markedly injected conjunctiva, diffused chemosis with mild proptosis, mucopurulent discharge, diffused corneal edema with neovascularization involving an area of previous infiltration, and marked anterior chamber reaction with plasmoid aqueous in the left eye . Since orbital cellulitis could not be ruled out, a computerized tomography scan of the orbit was performed, with the results showing localized preseptal swelling and scleral thickening of the left eye . B-scan ultrasonography showed diffuse scleral thickening and exudative retinal detachment . The results of previous microbial workup demonstrated Basidiobolus species . The patient was treated with ketoconazole 2% eye drops hourly, subconjunctival injection of fluconazole 1 mg every other day, oral itraconazole 200 mg daily, oral trimethoprim 400 mg, and sulfamethoxazole 80 mg 2 tablets twice daily. In addition, diabetes mellitus was identified during his general workup, thus antidiabetic drugs were given. Five days after treatment, his left eye developed more proptosis and limitation of extraocular movement, increased chemosis as well as diffused corneal stromal and subepithelial infiltration . Corneal confocal microscopy was done and showed multiple round to oval-shaped lesions which looked like fungal zygospores in the corneal stroma . The patient then underwent exploratory surgical intervention. Multiple scleral abscesses were found. Pus from the abscess was sent for microbial study showing fungal hyphae and zygospores . The fungal culture also demonstrated Basidiobolus sp. and the nucleotide sequence indicated B. ranarum . Oral itraconazole was increased to 400 mg daily. Eight days after treatment, the lesions seemed to respond to treatments as the proptosis, chemosis, and limitation of extraocular motions decreased, but generalized stromal and subepithelial infiltrations were still seen in the left eye. Nevertheless, the patient rejected further treatment and wanted to be treated as an outpatient. Two weeks after discharge, BCVA of his left eye was still hand motion despite an improvement of other signs including proptosis, chemosis, limitation of extraocular motions, and corneal infiltrations. Since then, the patient was lost to follow-up.", + "fulltext_subclaims": [ + "The patient is a 47-year-old male.", + "The patient presented with a red eye, scleral nodule, and increased intraocular pressure in the left eye.", + "The symptoms had been present for 3 weeks.", + "The symptoms followed an eye injury from sawdust.", + "At a regional hospital, he was treated as nodular scleritis and secondary ocular hypertension.", + "He received topical prednisolone acetate 1% every 2 h.", + "He received nepafenac four times daily.", + "He received timolol maleate 0.5% and brimonidine tartrate 0.1% twice daily.", + "He received oral prednisolone 15 mg/day.", + "He received oral acetazolamide 250 mg twice daily.", + "The lesion did not improve after 1 week of treatment.", + "The patient was referred to a tertiary hospital.", + "His best corrected visual acuity was 6/6 in the right eye.", + "His best corrected visual acuity was 6/12 in the left eye.", + "Slit-lamp examination revealed a painless, slow-growing nodular lesion at the inferonasal area.", + "There was marked injection of conjunctiva.", + "There was mucopurulent discharge.", + "There was a small infiltration of the adjacent peripheral cornea.", + "The anterior chamber, the lens, and fundus were unremarkable.", + "The intraocular pressure was 20 mm Hg.", + "The patient was diagnosed as infectious scleritis with scleral abscess.", + "Both topical and oral steroids were discontinued.", + "A surgical drainage was performed.", + "Yellow pus from the abscess was sent for microbial study.", + "The smears showed no organism.", + "The culture did not grow any organism.", + "The patient was initially treated as infectious scleritis with fortified cefazolin (33 mg/mL) and fortified gentamycin (14 mg/mL) every 2 h.", + "He received oral ciprofloxacin 500 mg twice daily.", + "Eight days after treatment, the scleral nodule resolved.", + "The cornea was clear with controlled intraocular pressure.", + "The patient was discharged and instructed to follow up at the previous regional hospital.", + "Two weeks later, his vision got worse.", + "He went to the regional hospital.", + "Increased corneal haze and anterior chamber reaction with plasmoid aqueous and vitreous haze in the left eye were noticed.", + "He received fortified cefazolin and fortified gentamycin hourly to the left eye.", + "He received intravenous vancomycin 500 mg/day.", + "He received intravenous ceftazidime 1 g/day.", + "At the second referral, best corrected visual acuity was hand motion in the left eye.", + "Slit-lamp examination revealed markedly injected conjunctiva.", + "There was diffused chemosis with mild proptosis.", + "There was mucopurulent discharge.", + "There was diffused corneal edema with neovascularization involving an area of previous infiltration.", + "There was marked anterior chamber reaction with plasmoid aqueous in the left eye.", + "A computerized tomography scan of the orbit showed localized preseptal swelling and scleral thickening of the left eye.", + "B-scan ultrasonography showed diffuse scleral thickening and exudative retinal detachment.", + "The results of previous microbial workup demonstrated Basidiobolus species.", + "The patient was treated with ketoconazole 2% eye drops hourly.", + "He received subconjunctival injection of fluconazole 1 mg every other day.", + "He received oral itraconazole 200 mg daily.", + "He received oral trimethoprim 400 mg and sulfamethoxazole 80 mg 2 tablets twice daily.", + "Diabetes mellitus was identified during his general workup.", + "Antidiabetic drugs were given.", + "Five days after treatment, the left eye developed more proptosis and limitation of extraocular movement.", + "There was increased chemosis and diffused corneal stromal and subepithelial infiltration.", + "Corneal confocal microscopy showed multiple round to oval-shaped lesions which looked like fungal zygospores in the corneal stroma.", + "The patient underwent exploratory surgical intervention.", + "Multiple scleral abscesses were found.", + "Pus from the abscess was sent for microbial study.", + "The fungal culture demonstrated Basidiobolus sp.", + "The nucleotide sequence indicated B. ranarum.", + "Oral itraconazole was increased to 400 mg daily.", + "Eight days after treatment, the lesions seemed to respond to treatments.", + "Proptosis, chemosis, and limitation of extraocular motions decreased.", + "Generalized stromal and subepithelial infiltrations were still seen in the left eye.", + "The patient rejected further treatment and wanted to be treated as an outpatient.", + "Two weeks after discharge, best corrected visual acuity of the left eye was still hand motion.", + "The patient was lost to follow-up." + ], + "summary": "A 47-year-old male patient with nodular scleritis in the left eye after an eye injury from sawdust was treated as bacterial scleritis. The lesion improved with early surgical drainage and antibacterial therapy; then, he was discharged from the hospital. Thereafter, the patient was re-admitted due to progression of infectious scleritis with keratitis and orbital cellulitis. Surgical abscess drainage was performed again. The microbiological study demonstrated Basidiobolus ranarum. The patient was treated with topical ketoconazole, subconjunctival fluconazole injection, and oral itraconazole with partial response to the treatment. However, the patient eventually denied any further treatment and did not return for follow-up.", + "summary_subclaims": [ + "The patient is a 47-year-old male.", + "The patient had nodular scleritis in the left eye.", + "The nodular scleritis occurred after an eye injury from sawdust.", + "The patient was treated as bacterial scleritis.", + "The lesion improved with early surgical drainage and antibacterial therapy.", + "The patient was discharged from the hospital.", + "The patient was re-admitted due to progression of infectious scleritis.", + "The patient had keratitis.", + "The patient had orbital cellulitis.", + "Surgical abscess drainage was performed again.", + "The microbiological study demonstrated Basidiobolus ranarum.", + "The patient was treated with topical ketoconazole.", + "The patient received subconjunctival fluconazole injection.", + "The patient was treated with oral itraconazole.", + "The treatment resulted in partial response.", + "The patient eventually denied any further treatment.", + "The patient did not return for follow-up." + ] + }, + { + "id": "multiclinsum_test_28_en.txt", + "fulltext": "The patient was a 43-year-old man who had a soft tissue mass in the right paravertebral region discovered incidentally 1 mo earlier.\nThe patient had no other significant medical history.\nThere was no personal and family history.\nPhysical examination on admission revealed no pain or tenderness.\nThe results of routine blood and urine tests, blood biochemistry, and immune and infection indices were normal.\nPlain computed tomography (CT) showed a lobulated soft tissue mass on the right side of the T4/5 vertebra that measured about 47 mm × 28 mm in the transverse view and contained diffuse stippled calcification . The mass caused cortical scalloping of the right fourth rib , rim ossification, and narrowing of the myeloid cavity. Enhanced CT showed mild enhancement of the mass. T1-weighted magnetic resonance imaging (MRI) in the transverse view showed a lobulated tumor on the right side of the thoracic vertebra . The lesion was bordered by a hypointense rim and showed long Tl and T2 signals in the sagittal view on T1- weighted and T2-weighted images . On short tau inversion recovery imaging, the mass showed high signal intensity and contained mottling and patchy long TI and short T2 abnormal signals . Enhancement was seen predominantly at the periphery of the lesion on post-enhanced MRI .", + "fulltext_subclaims": [ + "The patient was a 43-year-old man.", + "The patient had a soft tissue mass in the right paravertebral region discovered incidentally 1 mo earlier.", + "The patient had no other significant medical history.", + "There was no personal and family history.", + "Physical examination on admission revealed no pain or tenderness.", + "The results of routine blood and urine tests, blood biochemistry, and immune and infection indices were normal.", + "Plain computed tomography showed a lobulated soft tissue mass on the right side of the T4/5 vertebra that measured about 47 mm × 28 mm in the transverse view.", + "The mass contained diffuse stippled calcification.", + "The mass caused cortical scalloping of the right fourth rib.", + "The mass caused rim ossification.", + "The mass caused narrowing of the myeloid cavity.", + "Enhanced CT showed mild enhancement of the mass.", + "T1-weighted MRI in the transverse view showed a lobulated tumor on the right side of the thoracic vertebra.", + "The lesion was bordered by a hypointense rim.", + "The lesion showed long T1 and T2 signals in the sagittal view on T1-weighted and T2-weighted images.", + "On short tau inversion recovery imaging, the mass showed high signal intensity.", + "The mass contained mottling and patchy long T1 and short T2 abnormal signals.", + "Enhancement was seen predominantly at the periphery of the lesion on post-enhanced MRI." + ], + "summary": "The patient was a 43-year-old man who had been incidentally found to have a mediastinal mass 1 mo earlier. Plain computed tomography showed a lobulated soft tissue mass on the right side of the T4/5 vertebra that measured about 47 mm × 28 mm in the transverse view and contained diffuse stippled calcification. The mass caused cortical scalloping of the right fourth rib and marginal bone sclerosis. Enhanced computed tomography showed mild enhancement of the mass. Magnetic resonance imaging showed a lobulated mass on the right side of the thoracic vertebra with long TI and T2 signals, mottling, and patchy long T1 and short T2 signals inside. The lesion had a hypointense rim. Enhanced magnetic resonance imaging showed enhancement predominantly at the periphery of the tumor. The tumor was approached through a right posterolateral thoracotomy, and parts of the fourth and fifth ribs were excised with the tumor. Postoperative pathological analysis revealed periosteal chondroma of the rib.", + "summary_subclaims": [ + "The patient was a 43-year-old man.", + "He had been incidentally found to have a mediastinal mass 1 mo earlier.", + "Plain computed tomography showed a lobulated soft tissue mass on the right side of the T4/5 vertebra.", + "The mass measured about 47 mm × 28 mm in the transverse view.", + "The mass contained diffuse stippled calcification.", + "The mass caused cortical scalloping of the right fourth rib.", + "The mass caused marginal bone sclerosis.", + "Enhanced computed tomography showed mild enhancement of the mass.", + "Magnetic resonance imaging showed a lobulated mass on the right side of the thoracic vertebra.", + "The lesion had long TI and T2 signals.", + "The lesion had mottling.", + "The lesion had patchy long T1 and short T2 signals inside.", + "The lesion had a hypointense rim.", + "Enhanced magnetic resonance imaging showed enhancement predominantly at the periphery of the tumor.", + "The tumor was approached through a right posterolateral thoracotomy.", + "Parts of the fourth and fifth ribs were excised with the tumor.", + "Postoperative pathological analysis revealed periosteal chondroma of the rib." + ] + }, + { + "id": "multiclinsum_test_2482_en.txt", + "fulltext": "A 31-year-old male patient presented to our clinic with symptoms of neck pain, back pain (pain in the lower cervical and upper thoracic region), and numbness in both arms for the last 3 months. His physical examination revealed hypoesthesia at the C4 and C5 dermatomes in both arms with no loss of strength. Cervical computed tomography (CT) showed a destructive and compressive lesion in the C4 vertebra corpus . The retropulsion caused by compression had narrowed the canal. The lesion was also seen to be completely wrapped around the vertebral foramen at the right C4 level and to extend to the lateral mass posteriorly in the axial sections on CT . Weinstein, Boriani, Biagini (WBB) classification was used for the classification of the tumor . In this case, the tumor was located at the regions 5, 6, 7, 8, and 9 and invaded all the layers except the dura mater. Corpectomy was performed to the C4 vertebra with an anterior approach together with discectomy to the upper and lower disc spaces during surgery. The lesion was seen to extend to the right C4 vertebral foramen in the surgical observation after corpectomy, and the tumor was carefully dissected 360° around the vertebral artery at this level. Once the vertebral artery was revealed, we entered between the mass extending posteriorly to the lateral mass, the spinal cord, and the vertebral artery and performed meticulous intracavitary curettage. In order to ensure stability after tumor excision, the upper and lower corpus endplates were decorticated with the curette. A corpectomy cage was placed into the C4 space, and the system was fixed by placing a plate screw on the upper and lower vertebra from the anterior . There was no additional neurological deficit postoperatively. The patient’s neurological complaints improved during the postoperative period. There was no residual or remaining tumor after resection. The pathological microscopical evaluation revealed a tumor rich in osteoclastic multinuclear giant cells interspersed in a stroma composed of cells with oval-fusiform nuclei. The pathological diagnosis was giant cell tumor of the bone . No recurrence was seen during 3 years of follow-up .", + "fulltext_subclaims": [ + "The patient is a 31-year-old male.", + "The patient had symptoms of neck pain, back pain, and numbness in both arms for the last 3 months.", + "Physical examination revealed hypoesthesia at the C4 and C5 dermatomes in both arms.", + "Cervical CT showed a destructive and compressive lesion in the C4 vertebra corpus.", + "The lesion was completely wrapped around the vertebral foramen at the right C4 level.", + "The lesion extended to the lateral mass posteriorly in the axial sections on CT.", + "The WBB classification was used for the tumor classification.", + "The tumor was located at regions 5, 6, 7, 8, and 9.", + "The tumor invaded all the layers except the dura mater.", + "Corpectomy was performed to the C4 vertebra with an anterior approach.", + "Discectomy was performed to the upper and lower disc spaces.", + "The lesion extended to the right C4 vertebral foramen in surgical observation after corpectomy.", + "The tumor was carefully dissected 360° around the vertebral artery at the right C4 level.", + "Intracavitary curettage was performed after the vertebral artery was revealed.", + "The upper and lower corpus endplates were decorticated with the curette.", + "A corpectomy cage was placed into the C4 space.", + "A plate screw was placed on the upper and lower vertebra from the anterior.", + "There was no additional neurological deficit postoperatively.", + "The patient’s neurological complaints improved during the postoperative period.", + "There was no residual or remaining tumor after resection.", + "The pathological diagnosis was giant cell tumor of the bone.", + "No recurrence was seen during 3 years of follow-up." + ], + "summary": "A 31-year-old male patient presented with neck pain. Cervical CT revealed a lytic lesion extending posteriorly and causing the collapse of the C4 vertebra corpus. The patient underwent excision of the tumor extending from the anterior to the posterior with a single-stage anterior intervention followed by the placement of an anterior cage and plate-screw system for fusion. The pathology was reported as GCT.", + "summary_subclaims": [ + "The patient is a 31-year-old male.", + "The patient presented with neck pain.", + "Cervical CT revealed a lytic lesion.", + "The lesion extended posteriorly.", + "The lesion caused the collapse of the C4 vertebra corpus.", + "The patient underwent excision of the tumor.", + "The tumor extended from the anterior to the posterior.", + "The patient had a single-stage anterior intervention.", + "An anterior cage was placed.", + "A plate-screw system was placed for fusion.", + "The pathology was reported as GCT." + ] + }, + { + "id": "multiclinsum_test_454_en.txt", + "fulltext": "A 29-year-old man was hospitalized with progressive memory impairment for 10 days. He was reported to struggle remembering different locations, especially home-base. His medical history included an epileptic seizure 3 months prior to admission, without early diagnosis and treatment. The parents denied that he had promiscuous sexual behavior with any other persons. On examination, an ulcer was noted on the anterior perineum. The patient was disoriented in space, and he did not even know the result of 93 minus 7. His Mini-Mental State Examination (MMSE) score was 22 out of 30. The remainder of his neurologic examination was normal. An electroencephalogram showed diffuse generalized slow spike-wave discharges. The blood work-up indicated a positive tolulized red unheated serum test (TRUST) with a titer of 1:32 and a positive fluorescent treponemal antibody-absorbed (FTA-ABS) test. Serum biochemistry, HIV and hepatitis serology, thyroid stimulating hormone, and glycated hemoglobin levels were unremarkable. Brain MRI showed high signal intensities on FLAIR images involving of bilateral medial and anterior temporal structures, insula, right pulvinar of the thalami, precuneus, frontal and temporo-occipital lobes, with focal meningeal enhancement , while MR-TOF angiography did not reveal any evidence of intracranial arterial stenosis. Lumbar puncture with CSF analysis was performed with an opening pressure of 15.5 cmH2O, which revealed pleocytosis (58 cells/µL), low glucose (2.18 mmol/L), and raised protein (1.39 g/L), his CSF TRUST also showed positive titres of 1:2. Furthermore, CSF sample was collected for mNGS to rule out co-infection. Interestingly, after 48 h, the results revealed 2288 sequence reads uniquely corresponding to the Treponema pallidum genome with 11.6483% coverage , confirming the diagnosis of neurosyphilis. Meanwhile, no other causative pathogen was identified. Following treatment with intravenous penicillin, 24 million units/day for two weeks, his memory and computation abilities improved greatly, and the MMSE score increased to 27 points. Repeat MRI of the brain performed on 16th day of admission showed shrinkage of FLAIR signal abnormalities within the right precuneus, frontal, temporo-occipital, and bilateral mesial temporal regions, without leptomeningeal enhancement . On the recent follow-up occasion, he was nearly a normal person and refused repeat testing, including lumbar puncture.", + "fulltext_subclaims": [ + "The patient was a 29-year-old man.", + "He was hospitalized with progressive memory impairment for 10 days.", + "He struggled remembering different locations, especially home-base.", + "He had an epileptic seizure 3 months prior to admission.", + "The parents denied that he had promiscuous sexual behavior with any other persons.", + "An ulcer was noted on the anterior perineum.", + "The patient was disoriented in space.", + "He did not know the result of 93 minus 7.", + "His Mini-Mental State Examination (MMSE) score was 22 out of 30.", + "An electroencephalogram showed diffuse generalized slow spike-wave discharges.", + "The blood work-up indicated a positive tolulized red unheated serum test (TRUST) with a titer of 1:32.", + "The blood work-up indicated a positive fluorescent treponemal antibody-absorbed (FTA-ABS) test.", + "Brain MRI showed high signal intensities on FLAIR images involving bilateral medial and anterior temporal structures.", + "Brain MRI showed high signal intensities on FLAIR images involving the insula.", + "Brain MRI showed high signal intensities on FLAIR images involving the right pulvinar of the thalami.", + "Brain MRI showed high signal intensities on FLAIR images involving the precuneus.", + "Brain MRI showed high signal intensities on FLAIR images involving the frontal and temporo-occipital lobes.", + "Brain MRI showed focal meningeal enhancement.", + "MR-TOF angiography did not reveal any evidence of intracranial arterial stenosis.", + "Lumbar puncture with CSF analysis was performed.", + "The opening pressure was 15.5 cmH2O.", + "CSF analysis revealed pleocytosis (58 cells/µL).", + "CSF analysis revealed low glucose (2.18 mmol/L).", + "CSF analysis revealed raised protein (1.39 g/L).", + "CSF TRUST showed positive titres of 1:2.", + "CSF sample was collected for mNGS to rule out co-infection.", + "After 48 h, the mNGS results revealed 2288 sequence reads uniquely corresponding to the Treponema pallidum genome.", + "The mNGS results showed 11.6483% coverage of the Treponema pallidum genome.", + "The diagnosis of neurosyphilis was confirmed.", + "No other causative pathogen was identified.", + "He was treated with intravenous penicillin, 24 million units/day for two weeks.", + "His memory and computation abilities improved greatly.", + "His MMSE score increased to 27 points.", + "Repeat MRI of the brain performed on the 16th day of admission showed shrinkage of FLAIR signal abnormalities within the right precuneus.", + "Repeat MRI showed shrinkage of FLAIR signal abnormalities within the frontal regions.", + "Repeat MRI showed shrinkage of FLAIR signal abnormalities within the temporo-occipital regions.", + "Repeat MRI showed shrinkage of FLAIR signal abnormalities within the bilateral mesial temporal regions.", + "Repeat MRI showed no leptomeningeal enhancement.", + "On the recent follow-up occasion, he was nearly a normal person.", + "He refused repeat testing, including lumbar puncture." + ], + "summary": "In this report, we describe a case of neurosyphilis in a HIV-negative, 29-year-old man, who was admitted to our hospital with an epileptic seizure and progressive cognitive impairment. Brain magnetic resonance imaging (MRI) revealed fluid-attenuated inversion recovery (FLAIR) high signal intensities in bilateral medial and anterior temporal lobes, insula, right pulvinar of the thalami, precuneus, frontal and temporo-occipital lobes. Laboratory examination showed positive results by means of nontreponemal or specific treponemal test in serum and CSF. mNGS of the CSF was also performed to identify Treponema pallidum for the first time.", + "summary_subclaims": [ + "The patient is a 29-year-old man.", + "The patient is HIV-negative.", + "The patient was admitted with an epileptic seizure.", + "The patient had progressive cognitive impairment.", + "Brain MRI showed FLAIR high signal intensities in bilateral medial and anterior temporal lobes.", + "Brain MRI showed FLAIR high signal intensities in the insula.", + "Brain MRI showed FLAIR high signal intensities in the right pulvinar of the thalami.", + "Brain MRI showed FLAIR high signal intensities in the precuneus.", + "Brain MRI showed FLAIR high signal intensities in frontal lobes.", + "Brain MRI showed FLAIR high signal intensities in temporo-occipital lobes.", + "Laboratory examination showed positive results by nontreponemal test in serum.", + "Laboratory examination showed positive results by specific treponemal test in serum.", + "Laboratory examination showed positive results by nontreponemal test in CSF.", + "Laboratory examination showed positive results by specific treponemal test in CSF.", + "mNGS of the CSF was performed to identify Treponema pallidum for the first time." + ] + }, + { + "id": "multiclinsum_test_3155_en.txt", + "fulltext": "A previously healthy 21 year old Sri Lankan female university student admitted with shortness of breath for 1 week duration. Shortness of breath was mainly on exertion, however at the time of admission it was present even at rest. She had low grade fever for the last 1 week associated with malaise and profuse sweating. Her weight and appetite have been steady throughout. She was not on any long term medication and did not take medication for minor ailments in the recent past to suggest a drug induced hypersensitivity reaction. She does not have a history of conjunctivitis, rhinitis, sinusitis or allergy to any drug or food. She took worm treatment 6 month prior. History was negative for malignancy, thromboembolic disorders and connective tissue diseases. She denied family history or other risk factors for cardiovascular disease. She is a non alcoholic, non smoker and no history of illicit drug use. She was mildly febrile and dyspnoeic at rest. There was no associated pallor or icterus. Generalized oedema or ankle oedema was absent. Physical examination was negative for malignancy, thromboembolic disorders and connective tissue diseases. She was tachycardic with regular, low volume pulse at rate of 120 beats per minute. Jugular venous pressure was elevated 5 cm above the angle of Louis with negative Kussmaul sign. Her blood pressure was 100/70 mmHg on admission. The cardiac apex was at its normal position and heart sounds were slightly muffled with gallop rhythm. There were bilateral basal fine end inspiratory crackles. Firm, non tender mild hepatomegaly with mild splenomegaly were present. Otherwise her clinical examination was normal. Her full blood count revealed absolute rise in eosinophil count of 21.6 × 103 per microliter (63.5%) with 34 leukocytes per microliter with normal platelet count, haemoglobin and red cell indices. Blood picture showed high total white cell count with severe eosinophilia with no abnormal cells. Her erythrocyte sedimentation rate was 60 mm in 1st h in the presence of normal C-reactive protein. Sinus tachycardia with wide spread ST depression was evident on electrocardiogram. Chest X-ray was normal other than the evidence of heart failure. 2D-echocardiogram showed global left ventricular hypokinesia with 40% ejection fraction and thin layer of pericardial effusion. There was no associated intra cardiac thrombus. Troponin I was elevated up to 35.4 ng/dL (< 1.0 ng/dL) and Brain natriuretic peptide was 1280.5 pg/mL. Her renal function, thyroid function, serum electrolyte, calcium, magnesium levels, lipid profile were all normal with normal liver function but elevated liver enzymes (both were at 3 times upper limit of normal). Both serum IgM and IgG were negative for Filaria, Toxoplasma and toxocara infection and stool examination was negative for parasites. Serology for Epstein-Barr virus, Cytomegalo virus and Mycoplasma were negative. Retroviral infection and tuberculosis were excluded. Her blood culture and autoimmune screen were negative. Mild hepatosplenomegaly without lymphadenopathy was detected in otherwise normal ultrasound scan. Bone marrow biopsy showed hypereosinophilia with no evidence of bone marrow infiltration by lymphoproliferative malignancy. FIP1L1–PDGFRA fusion transcript and BCR–ABL transcript were not detected. The patient declined to undergo a confirmatory endomyocardial biopsy. Coronary angiogram and other non invasive cardiac imaging were not performed due to the practical problems of getting them done as they were not freely available. Clinically detected heart failure was confirmed by 2D ECHO and biochemical markers. The presence of global left ventricular dysfunction was better explained with myocarditis than myocardial infarction as there should be multi territory ischaemia to explain it which was less likely in our patient given that she was young and did not had any cardiovascular risk factors. This would have been excluded in certainty with coronary angiogram if it was freely available to us. Peripheral blood eosinophilia pointed towards a probable cause of cardiac damage in an otherwise healthy young female without cardiovascular risk factors. Drug hypersensitivity as a cause of eosinophilia was excluded from history. Bone marrow examination confirmed the diagnosis of hypereosinophilia. Myeloproliferative hypereosinophilic syndrome can give rise to chronic eosinophilic leukaemia. The possibility of this was excluded by negative FIP1L1–PDGFRA and BCR–ABL gene transcription. Secondary causes for hypereosinophilia were excluded and the diagnosis of idiopathic hypereosinophilic syndrome and eosinophilic myocarditis was made depending on the available investigations. Normal thyroid function test, negative ANA, DsDNA, negative antibody tires of common viral infection were used to exclude other differential diagnosis. This young female was given supportive care and treatment for heart failure and monitored in the high dependency unit to observe for possible deterioration. Her blood pressure dropped to 80/60 mmHg on day four of the admission requiring inotropic support. She was treated with intravenous Noradrenaline 0.3 μg/kg/min initially through L/Internal jugular venous catheter and then it was titrated up to 0.5 μg/kg/min to maintain mean arterial pressure of 70 mmHg. As soon as the diagnosis of hypereosinophilic syndrome with eosinophilic myocarditis was made, she was started on methylprednisolone 1 g/day for 3 days and continued with prednisolone 1 mg/kg to a total dose of 50 mg. Her symptoms started responding after the 3rd dose of methylprednisolone. Clinical improvement was observed in terms of symptoms and other parameters like blood pressure and pulse rate. Noradrenaline was then tailed off gradually and stopped after 5 days of starting steroids. Eosinophil count started to drop on day 5 of steroid treatment and it was then 16.31 × 103 per microliter. Troponin level gradually normalized over the period of the next 2 weeks. She was discharged after 3 weeks of hospital stay and by this time Eosinophil count was 1.11 × 103 per microliter (7.5%) and 2D echocardiography showed ejection fraction of 50% with thin layer of pericardial effusion. Pericardial effusion completely resolved and left ventricular function became normal (EF 60%) in the follow up 2D-ECHO and eosinophil count was at just upper limit of normal (0.52 × 103 per microliter) after 2 week of discharge from the hospital.\n\nSteroid dose was started to taper off after 1 month when she was totally asymptomatic and having persistently normal eosinophil count and left ventricular function. She is now on long term maintenance dose of steroid of 5 mg daily and Steroid needs to be continued at least 6 months to 1 year. She is on regular clinic follow up with monitoring of blood counts.", + "fulltext_subclaims": [ + "The patient is a 21 year old Sri Lankan female university student.", + "She had shortness of breath for 1 week.", + "Shortness of breath was mainly on exertion.", + "At the time of admission, shortness of breath was present even at rest.", + "She had low grade fever for the last 1 week.", + "She had malaise and profuse sweating.", + "Her weight and appetite have been steady.", + "She was not on any long term medication.", + "She did not take medication for minor ailments in the recent past.", + "She does not have a history of conjunctivitis, rhinitis, sinusitis, or allergy to any drug or food.", + "She took worm treatment 6 months prior.", + "History was negative for malignancy, thromboembolic disorders, and connective tissue diseases.", + "She denied family history or other risk factors for cardiovascular disease.", + "She is a non alcoholic, non smoker, and has no history of illicit drug use.", + "She was mildly febrile and dyspnoeic at rest.", + "There was no associated pallor or icterus.", + "Generalized oedema or ankle oedema was absent.", + "Physical examination was negative for malignancy, thromboembolic disorders, and connective tissue diseases.", + "She was tachycardic with a regular, low volume pulse at a rate of 120 beats per minute.", + "Jugular venous pressure was elevated 5 cm above the angle of Louis.", + "The Kussmaul sign was negative.", + "Her blood pressure was 100/70 mmHg on admission.", + "The cardiac apex was at its normal position.", + "Heart sounds were slightly muffled with gallop rhythm.", + "There were bilateral basal fine end inspiratory crackles.", + "Firm, non tender mild hepatomegaly was present.", + "Mild splenomegaly was present.", + "Otherwise her clinical examination was normal.", + "Her full blood count revealed an absolute rise in eosinophil count of 21.6 × 103 per microliter.", + "The eosinophil count was 63.5%.", + "There were 34 leukocytes per microliter.", + "The platelet count, haemoglobin, and red cell indices were normal.", + "Blood picture showed high total white cell count with severe eosinophilia.", + "There were no abnormal cells.", + "Her erythrocyte sedimentation rate was 60 mm in the first hour.", + "C-reactive protein was normal.", + "Sinus tachycardia with widespread ST depression was evident on electrocardiogram.", + "Chest X-ray was normal other than the evidence of heart failure.", + "2D-echocardiogram showed global left ventricular hypokinesia.", + "The ejection fraction was 40%.", + "There was a thin layer of pericardial effusion.", + "There was no associated intra cardiac thrombus.", + "Troponin I was elevated up to 35.4 ng/dL.", + "Brain natriuretic peptide was 1280.5 pg/mL.", + "Renal function, thyroid function, serum electrolyte, calcium, magnesium levels, lipid profile were all normal.", + "Liver function was normal.", + "Elevated liver enzymes were present.", + "Both serum IgM and IgG were negative for Filaria, Toxoplasma, and toxocara infection.", + "Stool examination was negative for parasites.", + "Serology for Epstein-Barr virus, Cytomegalo virus, and Mycoplasma were negative.", + "Retroviral infection and tuberculosis were excluded.", + "Blood culture and autoimmune screen were negative.", + "Mild hepatosplenomegaly without lymphadenopathy was detected.", + "Bone marrow biopsy showed hypereosinophilia.", + "There was no evidence of bone marrow infiltration by lymphoproliferative malignancy.", + "FIP1L1–PDGFRA fusion transcript was not detected.", + "BCR–ABL transcript was not detected.", + "The patient declined to undergo a confirmatory endomyocardial biopsy.", + "Coronary angiogram and other non invasive cardiac imaging were not performed.", + "Clinically detected heart failure was confirmed by 2D ECHO and biochemical markers.", + "The presence of global left ventricular dysfunction was better explained with myocarditis than myocardial infarction.", + "Peripheral blood eosinophilia pointed towards a probable cause of cardiac damage.", + "Drug hypersensitivity as a cause of eosinophilia was excluded from history.", + "Bone marrow examination confirmed the diagnosis of hypereosinophilia.", + "Myeloproliferative hypereosinophilic syndrome can give rise to chronic eosinophilic leukaemia.", + "The possibility of this was excluded.", + "Secondary causes for hypereosinophilia were excluded.", + "The diagnosis of idiopathic hypereosinophilic syndrome and eosinophilic myocarditis was made.", + "Normal thyroid function test, negative ANA, DsDNA, and negative antibody tires of common viral infection were used to exclude other differential diagnosis.", + "The young female was given supportive care and treatment for heart failure.", + "She was monitored in the high dependency unit.", + "Her blood pressure dropped to 80/60 mmHg on day four of admission.", + "She was treated with intravenous Noradrenaline 0.3 μg/kg/min.", + "Noradrenaline was titrated up to 0.5 μg/kg/min.", + "She was started on methylprednisolone 1 g/day for 3 days.", + "She was continued with prednisolone 1 mg/kg to a total dose of 50 mg.", + "Her symptoms started responding after the 3rd dose of methylprednisolone.", + "Clinical improvement was observed in terms of symptoms and other parameters like blood pressure and pulse rate.", + "Noradrenaline was gradually tailed off and stopped after 5 days of starting steroids.", + "Eosinophil count started to drop on day 5 of steroid treatment.", + "Eosinophil count was 16.31 �� 103 per microliter.", + "Troponin level gradually normalized over the next 2 weeks.", + "She was discharged after 3 weeks of hospital stay.", + "Eosinophil count was 1.11 × 103 per microliter.", + "2D echocardiography showed ejection fraction of 50%.", + "Pericardial effusion completely resolved.", + "Left ventricular function became normal.", + "Ejection fraction was 60%.", + "Eosinophil count was at just upper limit of normal.", + "Steroid dose was started to taper off after 1 month.", + "She is now on long term maintenance dose of steroid of 5 mg daily.", + "Steroid needs to be continued at least 6 months to 1 year.", + "She is on regular clinic follow up with monitoring of blood counts." + ], + "summary": "A previously healthy 21 year old Sri Lankan female admitted with shortness of breath for 1 week duration with associated low grade fever and profuse sweating. She was mildly febrile and dyspnoeic with absent ankle oedema. She was tachycardic and had elevated Jugular venous pressure with negative Kussmaul sign. Blood pressure was 100/70 mmHg. Clinically there was no cardiomegaly and heart sounds were slightly muffled with gallop rhythm. Bilateral basal fine end inspiratory crackles and mild hepatosplenomegaly were noted. The laboratory examinations showed leucocytosis with severe eosinophilia with no abnormal cells. Her ESR, Troponin I and Brain natriuretic peptide were elevated with normal CRP and electrocardiogram showed sinus tachycardia with wide spread ST depression. Heart failure was evident on chest X-ray and 2D-echocardiogram showed global left ventricular hypokinesia with 40% ejection fraction and a thin layer of pericardial effusion. Mild hepatosplenomegaly without lymphadenopathy was detected in the ultrasound scan. Bone marrow biopsy showed hypereosinophilia with no evidence of bone marrow infiltration. FIP1L1–PDGFRA fusion transcript and BCR–ABL transcript were not detected. Secondary causes for hypereosinophilia were excluded and the diagnosis of idiopathic hypereosinophilic syndrome and eosinophilic myocarditis was made. She had good response to steroids clinically and biochemically with complete recovery of left ventricular function. She is now on steroid to be continued at least 6 months to 1 year.", + "summary_subclaims": [ + "The patient is a 21 year old Sri Lankan female.", + "She had shortness of breath for 1 week.", + "She had associated low grade fever.", + "She had profuse sweating.", + "She was mildly febrile.", + "She was dyspnoeic.", + "She had no ankle oedema.", + "She was tachycardic.", + "She had elevated Jugular venous pressure.", + "The Kussmaul sign was negative.", + "Her blood pressure was 100/70 mmHg.", + "Heart sounds were slightly muffled.", + "There was a gallop rhythm.", + "Bilateral basal fine end inspiratory crackles were noted.", + "Mild hepatosplenomegaly was noted.", + "The laboratory examinations showed leucocytosis.", + "The laboratory examinations showed severe eosinophilia.", + "There were no abnormal cells.", + "Her ESR was elevated.", + "Her Troponin I was elevated.", + "Her Brain natriuretic peptide was elevated.", + "Her CRP was normal.", + "The electrocardiogram showed sinus tachycardia.", + "The electrocardiogram showed widespread ST depression.", + "Heart failure was evident on chest X-ray.", + "2D-echocardiogram showed global left ventricular hypokinesia.", + "2D-echocardiogram showed 40% ejection fraction.", + "2D-echocardiogram showed a thin layer of pericardial effusion.", + "Mild hepatosplenomegaly without lymphadenopathy was detected in the ultrasound scan.", + "Bone marrow biopsy showed hypereosinophilia.", + "Bone marrow biopsy showed no evidence of bone marrow infiltration.", + "FIP1L1–PDGFRA fusion transcript was not detected.", + "BCR–ABL transcript was not detected.", + "Secondary causes for hypereosinophilia were excluded.", + "The diagnosis of idiopathic hypereosinophilic syndrome was made.", + "The diagnosis of eosinophilic myocarditis was made.", + "She had good response to steroids.", + "She had complete recovery of left ventricular function.", + "She is now on steroid to be continued at least 6 months to 1 year." + ] + }, + { + "id": "multiclinsum_test_1008_en.txt", + "fulltext": "A 46-year-old male was brought to the emergency department (ED) with complaints of two weeks of cough, fever, generalized myalgias, sore throat, with progressively worsening of shortness of breath, and night sweats. He was initially treated with amoxicillin-clavulanate for pneumonia for seven days as prescribed by his primary care physician. On day eight he began to have tremors without fevers, which resulted in difficulty ambulating. He denied any nausea, vomiting, diarrhea, constipation, chest or abdominal pain. He had no other relevant medical history, denied taking any other medications, and denied history of alcohol use. Before going into self-quarantine he noted that some of his co-workers were having flu-like symptoms but he was unaware whether they had been tested for COVID-19.\nOn physical examination in the ED his vital signs were blood pressure 130/87 millimeters of mercury, temperature 36.6° Celsius (97.9° Fahrenheit), pulse rate 108 beats per minute, respiratory rate 22 breaths per minute, and oxygenating at 96% on room air. On respiratory exam, he had clear and equal breath sounds bilaterally. Neurologic exam revealed intact mental status that was oriented to self, date, and place. He had no dysarthria, aphasia, or neglect. His cranial nerves exam was significant for saccadic intrusions with smooth pursuit. A generalized tremor was noted when the patient was lying down, which worsened with movement, and there was a postural tremor in all extremities. Heel-to-shin exam was non-dystaxic although tremulous, and there was a bilateral intention tremor. On motor exam, he had normal tone and five out of five strength of all muscle groups in the upper and lower extremities. He was noted to have a wide-based gait with unsteadiness, but there was no dysmetria, pronator drift or truncal ataxia. His sensation was intact to light touch. No other abnormalities were noted on physical exam.\nIn the ED he was evaluated by neurology due to the constant tremors. Computed tomography (CT) of the head and CT angiogram did not reveal any significant findings, toxicology report came back negative, and thyroid-stimulating hormone, thiamine, and folate levels were normal. Chest radiograph showed clear lungs without any focal consolidation. Magnetic resonance imaging (MRI) done during his hospital stay showed hyperintense foci in the bifrontal subcortical and deep white matter on scattered T2-weighted, fluid-attenuated inversion recovery. These findings likely represent sequalae of microangiopathic ischemic changes. His hospital course was uncomplicated, and respiratory status improved with supportive measures. Final impression by neurology was that these were essential tremors, and the decision was made to treat with propranolol from which patient reported some mild improvement of symptoms.", + "fulltext_subclaims": [ + "The patient is a 46-year-old male.", + "He was brought to the emergency department with complaints of two weeks of cough.", + "He had fever, generalized myalgias, sore throat, shortness of breath, and night sweats.", + "He was treated with amoxicillin-clavulanate for pneumonia for seven days.", + "On day eight he began to have tremors without fevers.", + "He denied nausea, vomiting, diarrhea, constipation, chest or abdominal pain.", + "He had no other relevant medical history.", + "He denied taking any other medications.", + "He denied history of alcohol use.", + "He noted that some co-workers were having flu-like symptoms.", + "He was unaware whether his co-workers had been tested for COVID-19.", + "On physical examination, his oxygen saturation was 96% on room air.", + "Neurologic exam revealed intact mental status.", + "He had saccadic intrusions with smooth pursuit.", + "A generalized tremor was noted when the patient was lying down.", + "The tremor worsened with movement.", + "There was a postural tremor in all extremities.", + "He had a wide-based gait with unsteadiness.", + "Computed tomography of the head did not reveal any significant findings.", + "Chest radiograph showed clear lungs without any focal consolidation.", + "MRI showed hyperintense foci in the bifrontal subcortical and deep white matter.", + "The findings likely represent sequalae of microangiopathic ischemic changes.", + "The final impression by neurology was that these were essential tremors.", + "The decision was made to treat with propranolol.", + "The patient reported some mild improvement of symptoms." + ], + "summary": "We describe a case of a 46-year-old man with COVID-19 infection complicated by a bilateral intention tremor and wide-based gait. Although neurological manifestations have been reported related to COVID-19, tremulousness has not yet been described.", + "summary_subclaims": [ + "The patient is a 46-year-old man.", + "The patient had a COVID-19 infection.", + "The patient had a bilateral intention tremor.", + "The patient had a wide-based gait.", + "Neurological manifestations have been reported related to COVID-19.", + "Tremulousness has not yet been described in relation to COVID-19." + ] + }, + { + "id": "multiclinsum_test_515_en.txt", + "fulltext": "A 65-year-old, right-handed Caucasian man was initially admitted to another hospital after a motor vehicle accident. Prior to the accident, he was an independent truck driver who lived with his wife. He was an ex-smoker of 50 pack-years, and had a significant family history in first-degree relatives of lung, brain, and cervical cancer. Other medical conditions included hypertension, psoriasis, and diverticular disease requiring bowel resection.\nThe patient was driving a truck alone when he crashed. When paramedics attended, the patient was found in the passenger seat, conscious but confused and combative. At this time, pulse and blood pressure were unmeasurable. Primary and secondary surveys in hospital showed no evidence of chest trauma, and the patient suffered only minor soft tissue injuries. In hospital telemetry revealed paroxysmal atrial fibrillation with rapid ventricular response, which was without symptoms and managed only with metoprolol – to the best of our knowledge, no other antiarrhythmic agents were used. Occasional 5-second sinus pauses were also noted, with preceding seizure activity and post-ictal altered level of consciousness for several minutes. Between events, electrocardiography (ECG) was otherwise unremarkable, with no evidence of ischemic changes or other conduction abnormalities. On the fourth day of admission, he became bradycardic and progressed to asystolic arrest requiring 4 minutes of cardiopulmonary resuscitation (CPR). Spontaneous circulation returned in the form of rapid atrial fibrillation. The patient was intubated, and had a temporary pacing wire inserted until a permanent pacemaker was inserted the next day. Cardiac workup, including troponin and electrolyte levels were within normal range. Echocardiography showed a mildly dilated left atrium of 25 cm2, with no other valvular, structural or wall motion abnormalities noted. There was no evidence of right heart strain on echocardiogram or ECG suggestive of pulmonary embolus. A diagnosis of sick sinus syndrome was made, and he was commenced on metoprolol and apixaban. His behavior remained impulsive after extubation, demanding to leave the hospital, and he was discharged several days later. All other investigations at this time, including chest X-ray, electroencephalogram (EEG) and a computed tomography (CT) brain scan, were unremarkable.\nOne week after discharge, he presented to our hospital with his first observed generalized tonic-clonic seizure (GTCS) lasting 3 minutes, with urinary incontinence and prolonged post-ictal confusion. Repeat EEG and CT brain were reported as normal. This episode was thought to be secondary to hypoxic brain injury after asystolic arrest. He was discharged on levetiracetam 1 g twice daily. Two weeks later he presented with another GTCS, and was discharged once stable from Emergency. His third seizure occurred 6 days later, at which time he was admitted and commenced on sodium valproate 500 mg twice daily in addition to levetiracetam. His EEG and CT brain scan were again normal. Two weeks later, his fourth GTCS prompted addition of carbamazepine 200 mg controlled release twice daily. An outpatient magnetic resonance imaging (MRI) brain scan showed no abnormality at this time.\nHe had three further seizures in 3 weeks, and tolerated several antiepileptic drugs poorly. He was admitted to our hospital 10 weeks after his first seizure due to confusion. Retrospectively, there was significant deterioration in his confusion, agitation, and impulsivity since his initial presentation, in addition to more frequent seizures. Of note, his wife also reported progressive slurring of his speech, difficulty walking, and ongoing back pain over the preceding weeks. Medications at this point were lacosamide 100 mg twice daily, and sodium valproate 1 g twice daily. He suffered no further seizures, but became agitated and aggressive, requiring one-to-one nursing, regular olanzapine, and four-point limb restraints.\nHis refractory and progressive symptoms prompted further investigation. EEG was again normal. Lumbar puncture showed normal opening pressures, with CSF findings as follows: leukocytes 2 × 106/L, mononuclear cells 2 × 106/L, protein 0.61 mg/dL, glucose 3.2 mmol/L. ANNA-1 (Hu) antibodies, GABAB-R antibodies and unmatched oligoclonal bands were also present. Serum was also positive for GABAB-R antibodies but not for anti-Hu antibodies. A chest CT scan revealed a spiculated mass in the right lung and perihilar lymphadenopathy. A biopsy was obtained via endobronchial ultrasound, which revealed small cell neuroendocrine tumor. A subsequent MRI spine scan revealed diffuse vertebral metastases.\nHe was commenced on etoposide and carboplatin, as well as a trial of intravenous immunoglobulin (IVIg). Although suffering chemotherapy-related side effects including febrile neutropenia from staphylococcal septicemia, he showed some improvement with this therapy. He remained seizure free, was able to hold a conversation and mobilise independently. His modified Rankin scale (mRS) was 4 prior to treatment, and improved to a mRS of 2 with IVIg and chemotherapy. At 12 weeks follow-up, our patient had only mild short-term memory deficits, but was otherwise at his premorbid level of function.", + "fulltext_subclaims": [ + "The patient was a 65-year-old, right-handed Caucasian man.", + "He was admitted to another hospital after a motor vehicle accident.", + "He was an ex-smoker of 50 pack-years.", + "He had a significant family history in first-degree relatives of lung, brain, and cervical cancer.", + "Other medical conditions included hypertension, psoriasis, and diverticular disease requiring bowel resection.", + "The patient was driving a truck alone when he crashed.", + "When paramedics attended, the patient was found in the passenger seat, conscious but confused and combative.", + "At this time, pulse and blood pressure were unmeasurable.", + "Primary and secondary surveys in hospital showed no evidence of chest trauma.", + "The patient suffered only minor soft tissue injuries.", + "In hospital telemetry revealed paroxysmal atrial fibrillation with rapid ventricular response.", + "The paroxysmal atrial fibrillation was without symptoms.", + "It was managed only with metoprolol.", + "To the best of our knowledge, no other antiarrhythmic agents were used.", + "Occasional 5-second sinus pauses were also noted.", + "There was post-ictal altered level of consciousness for several minutes.", + "Between events, electrocardiography (ECG) was otherwise unremarkable.", + "There was no evidence of ischemic changes or other conduction abnormalities.", + "On the fourth day of admission, he became bradycardic and progressed to asystolic arrest.", + "The asystolic arrest required 4 minutes of cardiopulmonary resuscitation (CPR).", + "Spontaneous circulation returned in the form of rapid atrial fibrillation.", + "The patient was intubated.", + "A temporary pacing wire was inserted until a permanent pacemaker was inserted the next day.", + "Cardiac workup, including troponin and electrolyte levels, were within normal range.", + "Echocardiography showed a mildly dilated left atrium of 25 cm2.", + "There was no other valvular, structural, or wall motion abnormalities noted.", + "There was no evidence of right heart strain on echocardiogram or ECG suggestive of pulmonary embolus.", + "A diagnosis of sick sinus syndrome was made.", + "He was commenced on metoprolol and apixaban.", + "His behavior remained impulsive after extubation, demanding to leave the hospital.", + "He was discharged several days later.", + "All other investigations at this time, including chest X-ray, electroencephalogram (EEG), and a computed tomography (CT) brain scan, were unremarkable.", + "One week after discharge, he presented with his first observed generalized tonic-clonic seizure (GTCS) lasting 3 minutes.", + "This episode was thought to be secondary to hypoxic brain injury after asystolic arrest.", + "He was discharged on levetiracetam 1 g twice daily.", + "Two weeks later he presented with another GTCS.", + "He was discharged once stable from Emergency.", + "His third seizure occurred 6 days later.", + "He was admitted and commenced on sodium valproate 500 mg twice daily in addition to levetiracetam.", + "His EEG and CT brain scan were again normal.", + "An outpatient magnetic resonance imaging (MRI) brain scan showed no abnormality at this time.", + "He had three further seizures in 3 weeks.", + "He tolerated several antiepileptic drugs poorly.", + "He was admitted to our hospital 10 weeks after his first seizure due to confusion.", + "Retrospectively, there was significant deterioration in his confusion, agitation, and impulsivity since his initial presentation.", + "His wife also reported progressive slurring of his speech, difficulty walking, and ongoing back pain over the preceding weeks.", + "Medications at this point were lacosamide 100 mg twice daily, and sodium valproate 1 g twice daily.", + "He suffered no further seizures.", + "He became agitated and aggressive, requiring one-to-one nursing, regular olanzapine, and four-point limb restraints.", + "His refractory and progressive symptoms prompted further investigation.", + "EEG was again normal.", + "Lumbar puncture showed normal opening pressures.", + "CSF findings were as follows: leukocytes 2 × 106/L, mononuclear cells 2 × 106/L, protein 0.61 mg/dL, glucose 3.2 mmol/L.", + "ANNA-1 (Hu) antibodies, GABAB-R antibodies, and unmatched oligoclonal bands were also present.", + "Serum was also positive for GABAB-R antibodies but not for anti-Hu antibodies.", + "A chest CT scan revealed a spiculated mass in the right lung and perihilar lymphadenopathy.", + "A biopsy was obtained via endobronchial ultrasound, which revealed small cell neuroendocrine tumor.", + "A subsequent MRI spine scan revealed diffuse vertebral metastases.", + "He was commenced on etoposide and carboplatin, as well as a trial of intravenous immunoglobulin (IVIg).", + "Although suffering chemotherapy-related side effects including febrile neutropenia from staphylococcal septicemia, he showed some improvement with this therapy.", + "He remained seizure free.", + "He was able to hold a conversation and mobilise independently.", + "His modified Rankin scale (mRS) was 4 prior to treatment.", + "It improved to a mRS of 2 with IVIg and chemotherapy.", + "At 12 weeks follow-up, our patient had only mild short-term memory deficits.", + "He was otherwise at his premorbid level of function." + ], + "summary": "A 65-year-old Caucasian man presented with multiple seizures, dysarthria and behavioral disturbance of unclear etiology, with associated asystolic cardiac arrest. Antibody testing showed anti-Gamma-aminobutyric acid-B receptor and anti-Hu antibodies in serum and Gamma-aminobutyric acid-B receptor autoantibodies in cerebrospinal fluid. The diagnosis of small cell lung cancer was subsequently made after lung biopsy, and the patient showed improvement with chemotherapy and intravenous immunoglobulin.", + "summary_subclaims": [ + "The patient is a 65-year-old Caucasian man.", + "The patient had multiple seizures.", + "The patient had dysarthria.", + "The patient had behavioral disturbance.", + "The etiology of the symptoms was unclear.", + "The patient had an associated asystolic cardiac arrest.", + "Antibody testing showed anti-Gamma-aminobutyric acid-B receptor antibodies in serum.", + "Antibody testing showed anti-Hu antibodies in serum.", + "Gamma-aminobutyric acid-B receptor autoantibodies were found in cerebrospinal fluid.", + "The diagnosis of small cell lung cancer was made after lung biopsy.", + "The patient showed improvement with chemotherapy.", + "The patient showed improvement with intravenous immunoglobulin." + ] + }, + { + "id": "multiclinsum_test_238_en.txt", + "fulltext": "A British Caucasian girl aged 14 years was referred to our clinic with a double thoracic scoliosis. She was diagnosed with RTS-2 on the basis of clinical findings and genetic testing. A physical examination demonstrated down-slanting palpebral fissures, bilateral proptosis, divergent squint right eye, micrognathia and microcephaly, a high arched and narrow palate, dental crowding, ears posteriorly rotated, and arachnodactyly. As part of the underlying condition, our patient had marked nasal speech and mild to moderate right conductive hearing impairment. She had developmental delay and attention deficit hyperactivity disorder. She had a learning disability (intelligence quotient (IQ) 60) and delay in fine motor skills. There was no history of recurrent chest infections or gastroesophageal reflux. There was no family history of syndromic conditions or scoliosis. The scoliosis was first noted at the age of 13 years during an assessment of a chest infection by her pediatrician. No treatment was given at that stage and the deformity gradually progressed. At presentation to our clinic, she was post-menarche with height 137cm, arm span 144cm, body weight 27kg, and body mass index 9.8kg/m2.\nOn clinical examination, our patient had a severe double left upper and right lower thoracic scoliosis. Her thoracic spine across the more severe right thoracic curve was rotated to the right, with marked ipsilateral prominence of her rib cage and scapula and associated hypokyphosis. There was also thoracic translocation and listing of her trunk to the right, with associated waistline asymmetry and prominence of the left side of her pelvis. Her pelvis was level with no evidence of leg-length discrepancy. There were no skin or soft tissue abnormalities overlying her spine. Our patient reported no neurological symptoms. A neurological examination confirmed normal tone, muscle power, sensation and tendon reflexes in her upper and lower limbs, as well as symmetrically elicited abdominal reflexes. There were no upper motor neuron signs. Moderate ligamentous laxity was noted.\nRadiographs of her spine during the initial assessment revealed a right thoracic scoliosis extending from T6 to L2, measuring 46°, and a left upper thoracic scoliosis extending from T1 to T6, measuring 30°. The rotatory component of the deformity resulted in marked thoracic hypokyphosis, which in turn significantly reduced the anteroposterior diameter of her chest, as well as the space available for her lungs. There were no congenital anomalies affecting her vertebral column or chest wall. There were also no features suggestive of congenital spinal stenosis, with the interpedicular distance within normal limits across all spinal segments. Her Risser grade was 0 with open triradiate cartilage bilaterally, indicating that she had significant remaining skeletal growth.\nBecause of the severity of her scoliosis, we decided to proceed with surgical correction. In the presence of the underlying syndromic condition, a pre-operative assessment was organized that included spinal magnetic resonance imaging (MRI) under general anesthesia as well as cardiac; anesthetic; ear, nose and throat; psychological; and respiratory reviews. We encountered extreme difficulty in concluding the pre-operative assessment because our patient’s anxiety, behavioral problems and poor cooperation resulted in severe delays.\nThe MRI of the spine demonstrated no intra-spinal anomalies, normal appearance of the pedicles and no spinal stenosis. There was no evidence of tracheal or bronchial obstruction. The psychological evaluation concluded that our patient was cognitively and emotionally younger than her chronological age and consistent with that of a child aged seven to eight years. The cardiac evaluation, including electrocardiogram and ultrasound, showed normal function. The respiratory review, including chest radiographs, capillary blood gas sample and sleep studies, demonstrated restrictive pulmonary disease with marked deterioration of lung functions, forced expiratory volume in one second (FEV1) 0.79L (38% predicted) and forced vital capacity (FVC) 0.88L (37% predicted). Pre-operative blood results were within normal limits. At the time of surgery, 10 months after her initial clinical presentation, the degree of scoliosis in the thoracic curves had progressed to 39° and 68° respectively. Both curvatures were significantly rigid on a supine maximum traction radiograph, with the flexibility index being 7% and 20% for the upper and lower thoracic scoliosis respectively.\nOur patient was admitted to our hospital on the day of surgery and the plan was for her to receive a dose of midazolam as pre-medication before transfer to theater. However, she refused to take her pre-medication or go to theater, despite efforts and involvement of allied health specialists (specialist spinal nurse, learning disability nurse and health play specialist). This resulted in cancellation of the procedure. Additional psychological support sessions were offered to our patient and the surgery was re-scheduled with a different anesthetic plan. A peripheral intravenous access was secured when performing pre-operative blood tests that allowed us to administer propofol and remifentanil in the Surgical Admissions Unit. She was subsequently transported to theater with an oxygen face mask, where intubation was performed without complications. There were no difficulties during intubation related to our patient’s craniofacial anomalies.Our patient (now 15 years old) underwent a posterior spinal arthrodesis extending from T2 to L4 with the use of a pedicle hook, screw and single concave rod instrumentation . We performed subperiosteal exposure of the spine to the tips of the transverse processes with extensive facetectomies to mobilize the curve and allow for placement of the instrumentation and extensive decortication. This was followed by an interfacetal and intertransverse arthrodesis using locally harvested bone from the spinous processes and supplemented by allograft bone. Correction of the scoliosis was achieved through apical translation, rod de-rotation, and proximal or distal distraction of the construct. We monitored her spinal cord during the operation, recording cortical and cervical somatosensory as well as transcranial motor evoked potentials, and there were no problems. A nasogastric tube was placed at completion of surgery to allow early instigation of feedings. Our patient was transferred to our intensive care unit still intubated.Our patient was extubated on her first post-operative day and remained in our intensive care unit for two days. Feedings were achieved through a nasogastric tube with the addition of nutritional supplements. An underarm spinal jacket was applied for six months after surgery to provide additional support. Her total hospital stay was 17 days and overnight nasogastric feedings were continued at home. Post-operative radiographs showed satisfactory correction of both thoracic curves to 18° and 30° respectively and restoration of the sagittal balance of her spine .\nAt her latest follow-up, two years and three months after surgery, our patient had no complaints of her back and she had returned to her normal activities. She was skeletally mature and spinal radiographs demonstrated no loss of scoliosis correction, no non-union and no add-on junctional deformity above or below the levels of the fusion. Repeat pulmonary function tests demonstrated a mild improvement in her lung function compared with her pre-operative tests, with FEV1 of 0.86L (47% predicted) and FVC of 0.94L (49% predicted).", + "fulltext_subclaims": [ + "The patient was a British Caucasian girl aged 14 years.", + "She was referred to the clinic with a double thoracic scoliosis.", + "She was diagnosed with RTS-2 on the basis of clinical findings and genetic testing.", + "A physical examination demonstrated down-slanting palpebral fissures.", + "A physical examination demonstrated bilateral proptosis.", + "A physical examination demonstrated divergent squint right eye.", + "A physical examination demonstrated micrognathia and microcephaly.", + "A physical examination demonstrated a high arched and narrow palate.", + "A physical examination demonstrated dental crowding.", + "A physical examination demonstrated ears posteriorly rotated.", + "A physical examination demonstrated arachnodactyly.", + "The patient had marked nasal speech.", + "The patient had mild to moderate right conductive hearing impairment.", + "The patient had developmental delay.", + "The patient had attention deficit hyperactivity disorder.", + "The patient had a learning disability (IQ 60).", + "The patient had delay in fine motor skills.", + "There was no history of recurrent chest infections.", + "There was no history of gastroesophageal reflux.", + "There was no family history of syndromic conditions.", + "There was no family history of scoliosis.", + "The scoliosis was first noted at the age of 13 years.", + "The scoliosis was noted during an assessment of a chest infection by her pediatrician.", + "No treatment was given at that stage.", + "The deformity gradually progressed.", + "At presentation to the clinic, she was post-menarche.", + "At presentation to the clinic, her height was 137cm.", + "At presentation to the clinic, her arm span was 144cm.", + "At presentation to the clinic, her body weight was 27kg.", + "At presentation to the clinic, her body mass index was 9.8kg/m2.", + "On clinical examination, the patient had a severe double left upper and right lower thoracic scoliosis.", + "The thoracic spine across the more severe right thoracic curve was rotated to the right.", + "There was marked ipsilateral prominence of the rib cage and scapula.", + "There was associated hypokyphosis.", + "There was thoracic translocation and listing of the trunk to the right.", + "There was associated waistline asymmetry.", + "There was prominence of the left side of the pelvis.", + "The pelvis was level.", + "There was no evidence of leg-length discrepancy.", + "There were no skin or soft tissue abnormalities overlying the spine.", + "The patient reported no neurological symptoms.", + "A neurological examination confirmed normal tone in the upper and lower limbs.", + "A neurological examination confirmed normal muscle power in the upper and lower limbs.", + "A neurological examination confirmed normal sensation in the upper and lower limbs.", + "A neurological examination confirmed normal tendon reflexes in the upper and lower limbs.", + "A neurological examination confirmed symmetrically elicited abdominal reflexes.", + "There were no upper motor neuron signs.", + "Moderate ligamentous laxity was noted.", + "Radiographs revealed a right thoracic scoliosis extending from T6 to L2, measuring 46°.", + "Radiographs revealed a left upper thoracic scoliosis extending from T1 to T6, measuring 30°.", + "The rotatory component of the deformity resulted in marked thoracic hypokyphosis.", + "The hypokyphosis significantly reduced the anteroposterior diameter of the chest.", + "The hypokyphosis significantly reduced the space available for the lungs.", + "There were no congenital anomalies affecting the vertebral column.", + "There were no congenital anomalies affecting the chest wall.", + "There were no features suggestive of congenital spinal stenosis.", + "The interpedicular distance was within normal limits across all spinal segments.", + "The patient's Risser grade was 0.", + "The patient had open triradiate cartilage bilaterally.", + "The patient had significant remaining skeletal growth.", + "Because of the severity of her scoliosis, surgical correction was decided.", + "A pre-operative assessment was organized.", + "The pre-operative assessment included spinal MRI under general anesthesia.", + "The pre-operative assessment included cardiac, anesthetic, ear, nose and throat, psychological, and respiratory reviews.", + "The pre-operative assessment was delayed due to the patient's anxiety.", + "The pre-operative assessment was delayed due to the patient's behavioral problems.", + "The pre-operative assessment was delayed due to the patient's poor cooperation.", + "The MRI of the spine demonstrated no intra-spinal anomalies.", + "The MRI demonstrated a normal appearance of the pedicles.", + "The MRI demonstrated no spinal stenosis.", + "There was no evidence of tracheal or bronchial obstruction.", + "The psychological evaluation concluded that the patient was cognitively and emotionally younger than her chronological age.", + "The psychological evaluation concluded that the patient was consistent with a child aged seven to eight years.", + "The cardiac evaluation, including electrocardiogram and ultrasound, showed normal function.", + "The respiratory review demonstrated restrictive pulmonary disease.", + "The FEV1 was 0.79L (38% predicted).", + "The FVC was 0.88L (37% predicted).", + "Pre-operative blood results were within normal limits.", + "At the time of surgery, the right thoracic curve had progressed to 68°.", + "At the time of surgery, the left thoracic curve had progressed to 39°.", + "Both curvatures were significantly rigid on a supine maximum traction radiograph.", + "The flexibility index was 7% for the upper thoracic scoliosis.", + "The flexibility index was 20% for the lower thoracic scoliosis.", + "The patient was admitted to the hospital on the day of surgery.", + "The plan was for the patient to receive a dose of midazolam as pre-medication.", + "The patient refused to take her pre-medication.", + "The patient refused to go to theater.", + "The procedure was cancelled.", + "Additional psychological support sessions were offered.", + "The surgery was re-scheduled.", + "A different anesthetic plan was used.", + "A peripheral intravenous access was secured.", + "Propofol and remifentanil were administered in the Surgical Admissions Unit.", + "The patient was transported to theater with an oxygen face mask.", + "Intubation was performed without complications.", + "There were no difficulties during intubation related to the patient's craniofacial anomalies.", + "The patient underwent a posterior spinal arthrodesis extending from T2 to L4.", + "The instrumentation included a pedicle hook, screw, and single concave rod.", + "Subperiosteal exposure of the spine to the tips of the transverse processes was performed.", + "Extensive facetectomies were performed to mobilize the curve.", + "An interfacetal and intertransverse arthrodesis was performed.", + "Locally harvested bone from the spinous processes was used.", + "Allograft bone was used.", + "Correction of the scoliosis was achieved through apical translation.", + "Correction of the scoliosis was achieved through rod de-rotation.", + "Correction of the scoliosis was achieved through proximal or distal distraction of the construct.", + "Spinal cord monitoring was performed.", + "Cortical and cervical somatosensory evoked potentials were recorded.", + "Transcranial motor evoked potentials were recorded.", + "There were no problems during spinal cord monitoring.", + "A nasogastric tube was placed at completion of surgery.", + "The patient was transferred to the intensive care unit still intubated.", + "The patient was extubated on her first post-operative day.", + "The patient remained in the intensive care unit for two days.", + "Feedings were achieved through a nasogastric tube.", + "Nutritional supplements were added.", + "An underarm spinal jacket was applied for six months after surgery.", + "The total hospital stay was 17 days.", + "Overnight nasogastric feedings were continued at home.", + "Post-operative radiographs showed satisfactory correction of both thoracic curves.", + "The right thoracic curve was corrected to 18°.", + "The left thoracic curve was corrected to 30°.", + "The sagittal balance of the spine was restored.", + "At her latest follow-up, two years and three months after surgery, the patient had no complaints of her back.", + "At her latest follow-up, the patient had returned to her normal activities.", + "The patient was skeletally mature.", + "Spinal radiographs demonstrated no loss of scoliosis correction.", + "Spinal radiographs demonstrated no non-union.", + "Spinal radiographs demonstrated no add-on junctional deformity above or below the levels of the fusion.", + "Repeat pulmonary function tests demonstrated a mild improvement in lung function.", + "The FEV1 was 0.86L (47% predicted).", + "The FVC was 0.94L (49% predicted)." + ], + "summary": "We present a 14-year-old British Caucasian girl with Rubinstein-Taybi type 2 syndrome who developed a severe double thoracic scoliosis measuring 39° and 68° respectively. Her scoliosis was associated with thoracic hypokyphosis, causing a marked reduction in the anteroposterior diameter of her chest and consequent severe restrictive lung disease. The deformity was noted by her local pediatrician as part of a chest infection assessment when she was aged 13 years, and gradually progressed as the result of spinal growth. Our patient underwent a posterior spinal arthrodesis using a single concave pedicle hook and screw rod construct and locally harvested autologous graft supplemented by allograft bone. This spinal fixation technique was selected because of our patient's low body weight to avoid prominence of the instrumentation causing skin healing problems and pain. Her scoliosis was corrected to 18° and 30° and we achieved a balanced spine in the coronal and sagittal planes. An underarm spinal jacket was provided for six months after surgery. During her latest follow-up at skeletal maturity, our patient had an excellent cosmetic outcome with no loss of deformity correction or detected pseudoarthrosis and a normal level of activities.", + "summary_subclaims": [ + "The patient is a 14-year-old British Caucasian girl with Rubinstein-Taybi type 2 syndrome.", + "She developed a severe double thoracic scoliosis measuring 39° and 68° respectively.", + "Her scoliosis was associated with thoracic hypokyphosis.", + "The deformity was noted by her local pediatrician as part of a chest infection assessment when she was aged 13 years.", + "The deformity gradually progressed as the result of spinal growth.", + "The patient underwent a posterior spinal arthrodesis using a single concave pedicle hook and screw rod construct.", + "The spinal fixation technique was selected because of the patient's low body weight.", + "The scoliosis was corrected to 18° and 30°.", + "An underarm spinal jacket was provided for six months after surgery.", + "During her latest follow-up at skeletal maturity, the patient had an excellent cosmetic outcome.", + "There was no loss of deformity correction or detected pseudoarthrosis." + ] + }, + { + "id": "multiclinsum_test_567_en.txt", + "fulltext": "A 64-year-old man underwent video-assisted thoracic surgery, right upper lobectomy combined with bronchoplasty, and SVC plasty for right lung cancer. General anesthesia was induced and maintained with propofol and remifentanil combined with paravertebral nerve block. After induction of anesthesia, propofol was administered at 2.5 μg/mL with a target-controlled infusion system (TCI pump TE-371TM; Terumo, Tokyo, Japan), and remifentanil was administered at 0.4 mg/h. Before clamping the SVC, the state entropy remained around 50 . Because the tumor had invaded the SVC, it was necessary to clamp the SVC for resection. After administration of 3000 units of heparin, the SVC was clamped on the cranial and caudal sides of the tumor, and the invading tumor was excised simultaneously with the SVC. Immediately after clamping, the mean arterial pressure (MAP) dropped from 60 to 50 mmHg. Blood pressure quickly recovered to its previous level after administration of 4 mg of ephedrine. State entropy rose temporarily for 4 min after clamping and then steeply slowed down to a value less than 10, and the burst suppression ratio (BSR) increased from 0 to 93% . The flattening of EEG was thought to be caused by cerebral congestion and reduced cerebral perfusion; however, the clamp could not be released because the SVC was already incised. We performed phlebotomy by releasing the clamp on the cranial side to relieve SVC congestion. Time course of an increase of MAP, phlebotomy, increase of state entropy (SE), and decrease of BSR should be correctly described. SE increased after declamping SVC . We performed phlebotomy with reference to the improvement in entropy EEG. Phlebotomies were performed twice during a total SVC clamping time of 21 min, for a total volume of 600 mL. State entropy gradually increased after SVC declamping and fully recovered 30 min after declamping . After the surgery time of 7 h and 12 min, he awakened from anesthesia and was extubated in the operating room. The patient was discharged without neurological sequelae.", + "fulltext_subclaims": [ + "The patient was a 64-year-old man.", + "The patient underwent video-assisted thoracic surgery.", + "The patient had a right upper lobectomy combined with bronchoplasty.", + "The patient had SVC plasty for right lung cancer.", + "General anesthesia was induced and maintained with propofol and remifentanil combined with paravertebral nerve block.", + "After induction of anesthesia, propofol was administered at 2.5 μg/mL with a target-controlled infusion system.", + "After induction of anesthesia, remifentanil was administered at 0.4 mg/h.", + "Before clamping the SVC, the state entropy remained around 50.", + "The tumor had invaded the SVC.", + "It was necessary to clamp the SVC for resection.", + "After administration of 3000 units of heparin, the SVC was clamped on the cranial and caudal sides of the tumor.", + "The invading tumor was excised simultaneously with the SVC.", + "Immediately after clamping, the mean arterial pressure dropped from 60 to 50 mmHg.", + "Blood pressure quickly recovered to its previous level after administration of 4 mg of ephedrine.", + "State entropy rose temporarily for 4 min after clamping.", + "State entropy then steeply slowed down to a value less than 10.", + "The burst suppression ratio increased from 0 to 93%.", + "The flattening of EEG was thought to be caused by cerebral congestion and reduced cerebral perfusion.", + "The clamp could not be released because the SVC was already incised.", + "We performed phlebotomy by releasing the clamp on the cranial side to relieve SVC congestion.", + "Phlebotomies were performed twice during a total SVC clamping time of 21 min.", + "The total volume of phlebotomy was 600 mL.", + "State entropy gradually increased after SVC declamping.", + "State entropy fully recovered 30 min after declamping.", + "The surgery time was 7 h and 12 min.", + "The patient awakened from anesthesia.", + "The patient was extubated in the operating room.", + "The patient was discharged without neurological sequelae." + ], + "summary": "A 64-year-old man underwent SVC clamping during lung tumor resection. The entropy and electroencephalogram monitoring values decreased with SVC clamping and increased in response to the release of congestion by phlebotomy and SVC declamping.", + "summary_subclaims": [ + "The patient is a 64-year-old man.", + "The patient underwent SVC clamping during lung tumor resection.", + "Entropy monitoring values decreased with SVC clamping.", + "Electroencephalogram monitoring values decreased with SVC clamping.", + "Monitoring values increased in response to the release of congestion by phlebotomy.", + "Monitoring values increased in response to SVC declamping." + ] + }, + { + "id": "multiclinsum_test_1510_en.txt", + "fulltext": "A 45-year-old male patient presented to our institute in December 2017. He suffered of kidney failure and multiple myeloma for about 10 years. The patient complained of dysphagia and respiratory difficulty. Clinical examination showed a big swelling of the neck. He had not shown any signs of systemic amyloidosis. There were no symptoms suggestive of hypo- or hyper-thyroidism. Ultrasound showed an increased volume of the thyroid gland (right lobe 49 × 38 × 100 mm; left lobe 41 × 34 × 51 mm.) with involvement of the mediastinum. No lateral cervical lymphadenopathy was appreciated. CT and MRI showed diffuse and multinodular enlargement of both lobes of the thyroid gland, no lateral cervical lymphadenopathy (right lobe reaches C2; left lobe reaches the brachio-cephalic trunk). Fine needle aspiration (FNA), performed in one nodule of 2 cm in its greatest dimension, showed the presence of colloid and histiocytes. The patient underwent total thyroidectomy. The post-operative course was unremarkable.\nGrossly, thyroid was diffusely enlarged with a nodular external surface (A). The cut surface showed a soft, irregularly nodular and salmon in color parenchyma (B). Histologically there was a diffuse stromal deposition of amorphus eosinophilic material, reminiscent of fibro-sclerotic changes (C and D). Residual normal-sized or cistically dilated thyroid follicles were seen (C and D). Notably some areas showed a variably fatty stromal component characterized by mature adipocytes (E). This component was interpreted as a fatty stromal metaplasia. PAS staining was negative or only weakly positive in the amorphus eosinophilic stromal material. Conversely, a positive staining was obtained with Rosso Congo stain (apple-green birefringence under polarized light). Based on morphological and histochemical features, the diagnosis of “amyloid goiter” was rendered.", + "fulltext_subclaims": [ + "The patient is a 45-year-old male.", + "He presented to the institute in December 2017.", + "He had kidney failure and multiple myeloma for about 10 years.", + "The patient complained of dysphagia.", + "The patient complained of respiratory difficulty.", + "Clinical examination showed a big swelling of the neck.", + "He had not shown any signs of systemic amyloidosis.", + "There were no symptoms suggestive of hypo- or hyper-thyroidism.", + "Ultrasound showed an increased volume of the thyroid gland.", + "The right lobe of the thyroid gland measured 49 × 38 × 100 mm.", + "The left lobe of the thyroid gland measured 41 × 34 × 51 mm.", + "Ultrasound showed involvement of the mediastinum.", + "No lateral cervical lymphadenopathy was appreciated.", + "CT and MRI showed diffuse and multinodular enlargement of both lobes of the thyroid gland.", + "The right lobe reaches C2.", + "The left lobe reaches the brachio-cephalic trunk.", + "Fine needle aspiration was performed in one nodule of 2 cm in its greatest dimension.", + "FNA showed the presence of colloid.", + "FNA showed the presence of histiocytes.", + "The patient underwent total thyroidectomy.", + "The post-operative course was unremarkable.", + "Grossly, the thyroid was diffusely enlarged with a nodular external surface.", + "The cut surface showed a soft, irregularly nodular and salmon in color parenchyma.", + "Histologically there was a diffuse stromal deposition of amorphus eosinophilic material.", + "Residual normal-sized or cistically dilated thyroid follicles were seen.", + "Some areas showed a variably fatty stromal component characterized by mature adipocytes.", + "This component was interpreted as a fatty stromal metaplasia.", + "PAS staining was negative or only weakly positive in the amorphus eosinophilic stromal material.", + "A positive staining was obtained with Rosso Congo stain.", + "Rosso Congo stain showed apple-green birefringence under polarized light.", + "Based on morphological and histochemical features, the diagnosis of 'amyloid goiter' was rendered." + ], + "summary": "We herein present a case of a 45-year-old male patient who complained of a big swelling in the neck. Ultrasound showed an enlarged thyroid gland with mediastinal involvement. The multinodular appearance was consistent with the diagnosis of multinodular goiter. He had a history of multiple myeloma but no sign of systemic amyloidosis.", + "summary_subclaims": [ + "The patient is a 45-year-old male.", + "The patient complained of a big swelling in the neck.", + "Ultrasound showed an enlarged thyroid gland.", + "Ultrasound showed mediastinal involvement.", + "The multinodular appearance was consistent with the diagnosis of multinodular goiter.", + "He had a history of multiple myeloma.", + "There was no sign of systemic amyloidosis." + ] + }, + { + "id": "multiclinsum_test_459_en.txt", + "fulltext": "A 43-year-old Caucasian woman, a mother of three sons, at 30 days post-partum after a full-term pregnancy without any complications and concluded by a vaginal delivery, suffering from diabetes on oral antidiabetic medication, presented to the emergency department with left flank pain with hematuria of one week’s duration. A clinical examination revealed an alert patient, febrile at 38°C, with blood pressure of 158 over 67mmHg, heart rate of 90 beats per minute, respiratory rate of 20 breaths per minute, suffering from pain in the left flank (visual analog score (VAS) = 5), this pain was exacerbated by palpation, which found lumbar contact. Diagnostic studies in the emergency room revealed a urine analysis with 104 white blood cells (WBCs), gross hematuria, and a C-reactive protein level of 88. Her blood cell count revealed anemia at 9g of hemoglobin; blood electrolytes and renal function with serum creatinine levels were normal.\nAn abdominal ultrasound scan showed discrete pyelocalyceal cavities dilation with a slightly enlarged left kidney and without visible urinary obstruction. A CT urography and angiography scan was performed and showed an ectatic left renal vein, seat of a large hypodense thrombus extending from the segmental renal veins to the inferior vena cava, with a large heterogeneous and hypodense region located in the medium and lower poles of the left kidney without urinary tract dilatation or tumoral lesions; this aspect concluded in a perfusion abnormality (renal venous infarction) (Figures and\n).\nAnticoagulation heparin therapy was started and our patient was admitted to a medical center for further investigations. Her proteinuria and blood cultures did not show any abnormalities, and her serum albumin levels were normal. The thrombophilia assessment, with protein C or S deficiency, mutation of coagulation factors II and V, lupus and antiphospholipid antibody syndrome (APS) tests, were negative. The outcome was favorable with disappearance of pain and, after five days of hospitalization, our patient was put on oral anticoagulant therapy (acenocoumarol 4mg/day) and discharged.", + "fulltext_subclaims": [ + "The patient is a 43-year-old Caucasian woman.", + "She is a mother of three sons.", + "She is 30 days post-partum after a full-term pregnancy.", + "The pregnancy was concluded by a vaginal delivery.", + "The pregnancy had no complications.", + "She has diabetes on oral antidiabetic medication.", + "She presented to the emergency department with left flank pain.", + "The pain was associated with hematuria.", + "The symptoms had been present for one week.", + "A clinical examination revealed a temperature of 38°C.", + "The blood pressure was 158 over 67mmHg.", + "The heart rate was 90 beats per minute.", + "The respiratory rate was 20 breaths per minute.", + "The pain was exacerbated by palpation.", + "The urine analysis showed 104 white blood cells.", + "The urine analysis showed gross hematuria.", + "The C-reactive protein level was 88.", + "The hemoglobin level was 9g.", + "The blood electrolytes were normal.", + "The serum creatinine levels were normal.", + "An abdominal ultrasound scan showed discrete pyelocalyceal cavities dilation.", + "The CT urography and angiography scan showed an ectatic left renal vein.", + "The CT scan showed a large hypodense thrombus extending from the segmental renal veins to the inferior vena cava.", + "The CT scan showed a large heterogeneous and hypodense region in the medium and lower poles of the left kidney.", + "The CT scan findings concluded in a perfusion abnormality (renal venous infarction).", + "Anticoagulation heparin therapy was started.", + "The patient was admitted to a medical center.", + "The proteinuria was normal.", + "The blood cultures were normal.", + "The serum albumin levels were normal.", + "The thrombophilia assessment was negative.", + "The outcome was favorable with disappearance of pain.", + "The patient was discharged after five days of hospitalization.", + "The patient was put on oral anticoagulant therapy (acenocoumarol 4mg/day)." + ], + "summary": "We report the case of a 43-year-old Caucasian woman, a mother of three sons who presented with left flank pain and hematuria. The clinical investigations did not find any other cause for her thrombophilia.", + "summary_subclaims": [ + "The patient is a 43-year-old Caucasian woman.", + "The patient is a mother of three sons.", + "The patient presented with left flank pain.", + "The patient presented with hematuria.", + "The clinical investigations did not find any other cause for her thrombophilia." + ] + }, + { + "id": "multiclinsum_test_1905_en.txt", + "fulltext": "A 4-day-old baby girl was referred from a paediatric tertiary care hospital for the genetic evaluation of bilateral asymmetric ectrodactyly. She is the second child of a non-consanguineous couple; a 25-year-old father and 23-year-old mother. The baby was delivered normally at term following an uncomplicated pregnancy. The birth weight was 2.5 kg and there were no post-natal complications. She had ectrodactyly involving three limbs, with the absence of the third digit on the left hand and the second and third digits on the right hand. The right thumb was clinically normal, but the fourth and fifth digits were malformed. The right foot had fixed clubfoot deformity with only 2 toes . There was no facial dysmorphism or facial clefts. Radiographs of the upper limbs showed complete absence of the metacarpal bone and the phalanges of the third digit in the left hand and absent metacarpals and phalanges of two digits on the right hand . During a subsequent evaluation of the proband at the pediatric clinic, right tibial hemimelia was documented in the patient’s medical records by the attending clinician, but the radiological images of the leg were not available for inclusion in this article. Cardiovascular, respiratory and abdominal examination showed no abnormalities. Ultrasonography of the abdomen, brain and bilateral hips were normal.\nThe mother also had bilateral ectrodactyly involving both hands, with the absence of the third digit on the right hand and two digits on the left hand. She had bi-phalangeal fifth digit on the left hand . She had not previously been investigated for this condition and was otherwise healthy without any remarkable events in the medical and obstetrics history. The first child of the couple who was aged 2 ½ years old at the time of consultation had normal growth and development with no congenital anomalies. There were no other family members or close relatives affected with similar limb deformities or other congenital anomalies.\nPeripheral venous blood samples were obtained from the baby and the mother with informed written consent. Genomic DNA was extracted from the blood samples and quantitative polymerase chain reaction (qPCR) was performed to identify rearrangements of the BHLHA9 gene (Chr17:1173858–1,174,565, hg19)(Ref Seq BHLHA9:NM_001164405). The RPPH1 gene (NR_002312) was used as the gene of reference. The qPCR results showed a BHLHA9/RPPH1 ratio of 1.46 in the baby and 1.50 in the mother confirming the BHLHA9 gene duplication. The unaffected sibling was not available for genetic assessment of her BHLHA9 status. Genetic counseling was offered to the family.\nAt the time of reporting, the baby was 10 months of age. Her body weight was 7.95 kg (25th centile), length was 72 cm (above 50th centile) and head circumference was 44 cm (between 25th and 50th centile). She had age-appropriate developmental milestones. Hearing and visual assessments were normal. Repeat ultrasonography of the brain and the abdomen showed no abnormalities. 2D-echocardiography showed a structurally and functionally normal heart. She is currently being followed up at the pediatric tertiary care hospital and awaiting reconstructive surgery.", + "fulltext_subclaims": [ + "A 4-day-old baby girl was referred for the genetic evaluation of bilateral asymmetric ectrodactyly.", + "The baby is the second child of a non-consanguineous couple.", + "The baby was delivered normally at term following an uncomplicated pregnancy.", + "The birth weight was 2.5 kg.", + "The baby had ectrodactyly involving three limbs.", + "The right foot had fixed clubfoot deformity with only 2 toes.", + "Radiographs of the upper limbs showed complete absence of the metacarpal bone and the phalanges of the third digit in the left hand.", + "Right tibial hemimelia was documented in the patient’s medical records.", + "The mother also had bilateral ectrodactyly involving both hands.", + "The mother had bi-phalangeal fifth digit on the left hand.", + "The first child of the couple had no congenital anomalies.", + "Genomic DNA was extracted from the blood samples.", + "Quantitative polymerase chain reaction (qPCR) was performed to identify rearrangements of the BHLHA9 gene.", + "The qPCR results showed a BHLHA9/RPPH1 ratio of 1.46 in the baby.", + "The qPCR results showed a BHLHA9/RPPH1 ratio of 1.50 in the mother.", + "The unaffected sibling was not available for genetic assessment.", + "The baby was 10 months of age at the time of reporting.", + "The baby’s body weight was 7.95 kg.", + "The baby’s length was 72 cm.", + "The baby’s head circumference was 44 cm.", + "The baby had age-appropriate developmental milestones.", + "Repeat ultrasonography of the brain and the abdomen showed no abnormalities.", + "2D-echocardiography showed a structurally and functionally normal heart.", + "The baby is currently being followed up at the pediatric tertiary care hospital." + ], + "summary": "The proband was a female child born to non-consanguineous parents. She was referred for genetic evaluation of bilateral asymmetric ectrodactyly involving both hands and right foot along with right tibial hemimelia. The right foot had fixed clubfoot deformity with only 2 toes. The mother had bilateral ectrodactyly involving both hands, but the rest of the upper limbs and both lower limbs were normal. Neither of them had any other congenital malformations or neurodevelopmental abnormalities. Genetic testing for rearrangement of BHLHA9 gene by quantitative polymerase chain reaction confirmed the duplication of the BHLHA9 gene in both the proband and the mother.", + "summary_subclaims": [ + "The proband was a female child born to non-consanguineous parents.", + "She was referred for genetic evaluation of bilateral asymmetric ectrodactyly involving both hands and right foot along with right tibial hemimelia.", + "The right foot had fixed clubfoot deformity with only 2 toes.", + "The mother had bilateral ectrodactyly involving both hands.", + "The rest of the upper limbs and both lower limbs were normal in the mother.", + "Neither of them had any other congenital malformations.", + "Neither of them had any neurodevelopmental abnormalities.", + "Genetic testing for rearrangement of BHLHA9 gene by quantitative polymerase chain reaction confirmed the duplication of the BHLHA9 gene in both the proband and the mother." + ] + }, + { + "id": "multiclinsum_test_103_en.txt", + "fulltext": "A 41-year-old primigravid woman, at 18 weeks gestation, with acute liver failure was referred to our transplant center for a trans-jugular liver biopsy and assessment for a potential liver transplant. Past medical history was unremarkable. The patient exhibited a ten-day history of persistent fever, headache, and acute hepatitis. Despite outpatient treatment with amoxicillin, cefixime, and acetaminophen, up to 1 gr three times per day for seven days, her symptoms did not improve. At admission (day zero), she was febrile (T 38.7 °C), alert, oriented, and hemodynamically stable. Physical examination revealed severe asthenia, pallor, sub-icteric sclera, and abdominal pain. Laboratory findings showed anemia (hemoglobin 8.3 g/dL), lymphopenia (1.4 × 103/μL), elevated transaminases (AST 7864 units/L, ALT 3012 units/L), hypoalbuminemia (1.5 g/dL), INR 1.4, increase in total bilirubin (1.6 mg/dL), and creatinine was 0.57 mg/dl. Inflammatory markers were elevated, with C-reactive protein (CRP) at 136 mg/L, (normal value 0–5 mg/L) procalcitonin (PCT) at 10.3 ng/mL, and ferritin at 36,185 ng/mL. Minimal peri-hepatic ascites was observed on abdominal ultrasound. Empiric antibiotic treatment with meropenem was initiated. The pathologist, at first evaluation of urgent liver biopsy, observed cytolytic liver damage with extensive centrilobular necrosis (acinar zone 3), suggestive of drug-induced damage. On day one after admission, the peripheral blood smear showed activated reactive and apoptotic lymphocytes. Serological tests for hepatitis A virus (HAV), hepatitis B virus (HBV), hepatitis C virus (HCV), cytomegalovirus (CMV), toxoplasmosis, and hepatitis E virus (HEV) were negative for acute infection. The plasma viral load of HSV-1 and 2, CMV, adenovirus, and varicella-zoster virus (VZV) was negative. Fecal samples tested negative for adenovirus, and molecular testing for respiratory viruses was also negative.\nDespite a negative HSV-1 and -2 viral load, serological analysis demonstrated positive HSV-1/2 IgM and borderline IgG antibodies. Consequently, a histological review of the liver biopsy was requested, revealing numerous cells with viral nuclear inclusions and a highly suggestive morphology for herpes virus cytopathic effects. Immuno-histochemical staining and real-time polymerase chain reaction (PCR) for HSV-2 were positive in the hepatic tissue , confirming the diagnosis. This was a primary HSV infection rather than a reactivation, as confirmed by the fourfold rise in IgG title observed four weeks after the first serological evaluation.\nAcyclovir treatment was initiated, leading to a progressive reduction in transaminases and inflammatory markers . However, on the fourth day, the patient’s clinical condition deteriorated, concomitantly with the development of anasarca attributed to severe hypoalbuminemia (1.8 g/dL) and an elevation in total bilirubin level (5.25 mg/dL). On the following day, the HSV-2 viral load became detectable, quantified at 28.750.000 copies/mL. The observed increase in inflammatory markers and high serum ferritin, despite optimized HSV-2 treatment, raised concerns of unregulated hyper-inflammation suggestive of a cytokine storm. Probability of hemophagocytic lymphohistiocytosis (HLH) using H score was 25–40% on day 4 and 80–88% on day 5 [, ]. By considering that steroids are usually not recommended in acute HSV infections and that cyclosporin may be unsafe during pregnancy .\nWe decided to administer human polyvalent immunoglobulin at a dose of 400 mg/kg/day for five days . The patient started to recover with a reduction in H score (with probability of HLH 25–40% on day 7, 8, 10, and 16–25% on day 12), inflammatory markers and in HSV-2 viral load to 1.361.205 copies/mL within one week. The patient became afebrile while HSV-1/2 DNA on the vaginal swab remained detectable. Thus, we recommended a cesarean delivery.\nAfter a total hospital stay of 20 days, including 19 days of acyclovir treatment, the patient was discharged with normalized inflammatory markers and recovery of liver function. On the follow-up visit, a month after discharge, she was asymptomatic with a viral load of HSV-2 of 120 copies/mL and a detectable HSV-1/2 vaginal swab. Obstetric examination revealed no discernible abnormalities in the fetus. The patient underwent a cesarean delivery at 33+s3 weeks of pregnancy. The newborn was a healthy girl with a birth weight of 1800 gr. HSV-1/2 DNA in plasma and cerebrospinal fluid of the newborn was undetectable. Both mother and baby are alive and well at the 6-month follow-up.\nUsing Luminex technology and the R software tool (version 4.1.2), we retrospectively analyzed plasma cytokine levels (stored at − 80 °C until their use) at five designated time points (day: 0–3–4–18–62) and correlated them with the clinical data after a z-score transformation. The heatmap generated in Fig. E revealed three discernible temporal biomarker clusters. The first cluster, represented by the acute phase (day 0 and day 3 after admission) in the absence of viremia, revealed an impaired specific antiviral immune response and, conversely, the production of cytokines and chemokines, including monokine induced by interferon-gamma (MIG), interferon-gamma (IFNγ), hepatocyte growth factor (HGF), monocyte chemoattractant protein-1 (MCP-1), interferon-gamma induced protein-10 (IP-10), C–C motif chemokine ligand 11 (CCL-11), and interleukin-8 (IL-8), IL-6, IL-1RA, IL-2R, and IL-10, all involved in inflammation. This profile was accompanied by increased hepatic (AST, ALT, bilirubin, gamma-GT, alkaline phosphatase, INR) and inflammatory (CRP, PCT, LDH, ferritin) biomarkers. In the second cluster, the viremic phase (day 4–18), we observed a reduction in the aforementioned inflammatory profile and an increase in total bilirubin, WBC, and neutrophils. Finally, in the third cluster (day 62, follow-up), we observed a complete recovery of hepatic markers and an increase in different cytokines involved in antiviral immunity, suggesting the onset of T cell responses involved in viral clearance and recovery from the infection. In Fig. F, we show the pairwise Pearson correlation analysis, which associates cytokine expression levels and laboratory values across the five-time points.", + "fulltext_subclaims": [ + "The patient was a 41-year-old primigravid woman at 18 weeks gestation.", + "She was referred to the transplant center for a trans-jugular liver biopsy and assessment for a potential liver transplant.", + "She had a ten-day history of persistent fever, headache, and acute hepatitis.", + "Outpatient treatment with amoxicillin, cefixime, and acetaminophen did not improve her symptoms.", + "At admission, she was febrile with a temperature of 38.7 °C.", + "Laboratory findings showed anemia with a hemoglobin of 8.3 g/dL.", + "Elevated transaminases were observed with AST at 7864 units/L and ALT at 3012 units/L.", + "Total bilirubin was 1.6 mg/dL.", + "The pathologist observed cytolytic liver damage with extensive centrilobular necrosis, suggestive of drug-induced damage.", + "Serological tests for HAV, HBV, HCV, CMV, toxoplasmosis, and HEV were negative for acute infection.", + "The plasma viral load of HSV-1 and 2, CMV, adenovirus, and VZV was negative.", + "Serological analysis demonstrated positive HSV-1/2 IgM and borderline IgG antibodies.", + "Histological review of the liver biopsy revealed numerous cells with viral nuclear inclusions and morphology suggestive of herpes virus cytopathic effects.", + "Immuno-histochemical staining and real-time PCR for HSV-2 were positive in the hepatic tissue, confirming the diagnosis.", + "The diagnosis was a primary HSV infection rather than a reactivation.", + "Acyclovir treatment was initiated.", + "On the fourth day, the patient’s clinical condition deteriorated.", + "The HSV-2 viral load became detectable at 28.750.000 copies/mL.", + "The probability of HLH using H score was 25–40% on day 4 and 80–88% on day 5.", + "Human polyvalent immunoglobulin was administered at a dose of 400 mg/kg/day for five days.", + "The patient started to recover with a reduction in H score to 25–40% on day 7.", + "The patient was discharged after a total hospital stay of 20 days.", + "The patient underwent a cesarean delivery at 33+s3 weeks of pregnancy.", + "The newborn was a healthy girl with a birth weight of 1800 gr.", + "HSV-1/2 DNA in plasma and cerebrospinal fluid of the newborn was undetectable.", + "Both mother and baby were alive and well at the 6-month follow-up." + ], + "summary": "A pregnant woman developed hepatitis due to a herpes simplex virus 2 primary infection with a severe systemic inflammatory response. Treatment with acyclovir and human immunoglobulin was given and both mother and baby survived.", + "summary_subclaims": [ + "A pregnant woman developed hepatitis due to a herpes simplex virus 2 primary infection.", + "The infection was associated with a severe systemic inflammatory response.", + "Treatment with acyclovir and human immunoglobulin was given.", + "Both mother and baby survived." + ] + }, + { + "id": "multiclinsum_test_1_en.txt", + "fulltext": "A 59-year-old man with a three-year history of hypertension presented with a one-day history of growing TP increasing stomach pain and frequent projectile vomiting, followed by absolute constipation for one day and abdominal distension six hours before presentation. No history of fever, malaise, jaundice, hematemesis, or melena was available. There was no family history of TB. He had a similar attack previously six months ago, which was conservatively controlled and he was discharged. He was alert, oriented, afebrile, and mildly dehydrated upon inspection. Abdominal examination revealed tenderness throughout the abdomen and increased bowel sounds. However, there was a palpable abdominal swelling. Rectum was found to be empty on digital rectal examination (DRE). He was originally managed by maintaining nothing by mouth, using O2 inhalation, nasogastric aspiration, and Foley catheterization. Intravenous fluid resuscitation was initiated, as well as empiric antibiotics. Blood tests revealed normal hepatic and renal profiles during laboratory workup. His coagulation profile was slightly abnormal, and he had metabolic alkalosis as determined by ABGs. LDH and CEA levels were within normal limits. Simple abdominal X-rays indicated Distended small bowel loops with varying air-fluid levels and an absence of rectum gas shadow, as shown in . Ultrasound of the abdomen was inconclusive.\nContrast-Enhanced Abdominal CT scan (CECT) showed Dilated fluid-filled Small Bowel loops (mainly Jejunal) with max. diameter of 4.5 cm, arranged strangely. Loops were enclosed in a thick membrane while a transition zone appears outside the enclosing membrane. A provisional diagnosis of Abdominal Cocoon Syndrome as given in . Keeping in mind the CT scans, consultant opted for exploratory laparotomy.\nPreparation for exploratory laparotomy was performed on the patient by the Consultant Surgeon.\nA midline incision was used to expose the abdomen and visualize the interior anatomy. Numerous jejuna and proximal ileum loops were discovered to be in a strong, thick, white membrane , which consisted of two layers. Within the sac's thick, fibrous outer membrane was a thin, avascular membrane. The liver, stomach, and jejunal/ileal loops were all covered in a dense sac. The Encasing Membrane was opened, adhesiolysis was performed, and the membrane was completely removed as Illustrated in a, b & c. The entire colon was healthy except for two locations where the gut wall had thinned out and friable, necessitating primary bowel repair. Additionally, the membrane was sent for histopathology. The abdomen was cleansed completely with normal saline and then closed with a drain friable.\nThe patient was released without difficulties on the fourth postoperative day and advised bed rest for a week. His osteopath's report revealed the following: Peritoneal tissue: A kind of fibrosis that is densely hyalinized, with mild chronic inflammation and dystrophic calcification. One of the surgery main complications is “bowel injury” and extra care should be taken in consideration.", + "fulltext_subclaims": [ + "The patient is a 59-year-old man.", + "He has a three-year history of hypertension.", + "He presented with a one-day history of growing stomach pain.", + "He had frequent projectile vomiting.", + "He had absolute constipation for one day.", + "He had abdominal distension six hours before presentation.", + "There was no history of fever.", + "There was no history of jaundice.", + "There was no family history of TB.", + "He had a similar attack six months ago.", + "The previous attack was conservatively controlled.", + "He was alert upon presentation.", + "He was mildly dehydrated upon inspection.", + "Abdominal examination revealed tenderness throughout the abdomen.", + "There was a palpable abdominal swelling.", + "Rectum was found to be empty on digital rectal examination.", + "He was managed with nothing by mouth.", + "O2 inhalation was used.", + "Nasogastric aspiration was used.", + "Intravenous fluid resuscitation was initiated.", + "Empiric antibiotics were started.", + "Blood tests revealed normal hepatic and renal profiles.", + "The coagulation profile was slightly abnormal.", + "ABGs showed metabolic alkalosis.", + "LDH levels were within normal limits.", + "CEA levels were within normal limits.", + "Simple abdominal X-rays showed distended small bowel loops with varying air-fluid levels.", + "There was an absence of rectum gas shadow on abdominal X-rays.", + "Contrast-Enhanced Abdominal CT scan showed dilated fluid-filled small bowel loops.", + "The loops were mainly jejunal.", + "The max. diameter of the loops was 4.5 cm.", + "The loops were enclosed in a thick membrane.", + "A transition zone appeared outside the enclosing membrane.", + "A provisional diagnosis of Abdominal Cocoon Syndrome was given.", + "The consultant opted for exploratory laparotomy.", + "A midline incision was used.", + "Numerous jejunal and proximal ileum loops were discovered in a strong, thick, white membrane.", + "The membrane consisted of two layers.", + "The outer membrane was thick and fibrous.", + "The inner membrane was thin and avascular.", + "The liver, stomach, and jejunal/ileal loops were covered in a dense sac.", + "The encasing membrane was opened.", + "Adhesiolysis was performed.", + "The membrane was completely removed.", + "The entire colon was healthy except for two locations.", + "The gut wall had thinned out and was friable in two locations.", + "Primary bowel repair was performed.", + "The membrane was sent for histopathology.", + "The abdomen was cleansed with normal saline.", + "The abdomen was closed with a drain.", + "The patient was released on the fourth postoperative day.", + "The patient was advised bed rest for a week.", + "The histopathology report showed densely hyalinized fibrosis.", + "There was mild chronic inflammation in the peritoneal tissue.", + "There was dystrophic calcification in the peritoneal tissue.", + "One of the surgery's main complications is bowel injury." + ], + "summary": "We present a 59-year-old man with severe intestinal blockage symptoms for three days. Rectum had a noticeable amount of abdominal fat. To rule out the more common causes of mechanical blockage, a CT scan revealed the presence of a rare condition called Cocoon Syndrome, which necessitated exploratory laparotomy and adhesiolysis surgery. After the surgery, the patient was declared stable and was released from the hospital.", + "summary_subclaims": [ + "The patient is a 59-year-old man.", + "The patient had severe intestinal blockage symptoms for three days.", + "The rectum had a noticeable amount of abdominal fat.", + "A CT scan was performed.", + "The CT scan revealed the presence of a rare condition called Cocoon Syndrome.", + "The patient underwent exploratory laparotomy and adhesiolysis surgery.", + "After the surgery, the patient was declared stable.", + "The patient was released from the hospital." + ] + }, + { + "id": "multiclinsum_test_2473_en.txt", + "fulltext": "A 58-year-old female presented to our clinic with a one-year history of blurry vision in her left eye. Her ocular history was unremarkable, except for the intolerance to contact lenses and amblyopia in her right eye. Her best-corrected distance visual acuity (CDVA) was 0.20 with -9.00/-1.50 x 25◦ in the right eye and 0.80 with +4.00 sphere correction in the left eye. Distance visual acuity was measured using a standard Snellen acuity chart at 6m and presented in decimals. Her best corrected near visual acuity (CNVA) was J9 with +2.50 and J1 with +2.50. The Jaeger eye chart was used in testing near vision acuity. On this card, on which paragraphs of text are printed, text sizes increase from 0.37 mm to 2.5 mm.\nSlit-lamp examination revealed incipient cataracts in both eyes, otherwise normal anterior segment findings. A dilated fundus examination revealed vitreous liquefaction and myopic macula in the right eye, otherwise normal findings of a posterior segment in both eyes. Intraocular pressure (IOP), measured with iCare (Tiolat Oy, Helsinki, Finland), was average at 18/19 mmHg (including correction factor of the corneal thickness). The axial length of the eye measured by the IOL master (IOLMaster 700; Carl Zeiss Meditec) of the right eye was 27.96 mm and 22.44 mm of the left. As a solution to the patient’s problem, due to intolerance to contact lenses, we had two possibilities: to implicate implantable collamer lens (ICL) or cataract surgery with intraocular lens (IOL) implantation. ICL implantation was no option due to the incipient cataract that already existed and the possibility of its progress in the future. So we decided on the second option. We wanted to choose an intraocular lens with which she would get the maximum. Considering the anisometropic amblyopia, we decided to implant the Eyhance lens. This type of lens has been designed to improve visual acuity contrast sensitivity and reduce the effects of glare in patients who have undergone cataract surgery. The procedure involved removing the patient’s natural lens and replacing it with the Eyhance lens. After a month, the patient’s visual acuity significantly improved in both eyes, with her best CDVA of the right eye now at 0.35 and her left eye at 0.95. Near visual acuity also improved, with the patient now able to read at J4 and J1 for her right and left eye, respectively, with +1.50 sphere correction. These improvements in vision have likely improved the patient’s quality of life and ability to perform daily activities. It’s important to note that cataract surgery carries potential risks and complications that the doctor should discuss with the patient beforehand. For this reason, it’s crucial that patients are well-informed about the procedure and its possible outcomes to make an informed decision about their treatment options.", + "fulltext_subclaims": [ + "The patient is a 58-year-old female.", + "She had a one-year history of blurry vision in her left eye.", + "Her ocular history was unremarkable, except for intolerance to contact lenses and amblyopia in her right eye.", + "Her best-corrected distance visual acuity (CDVA) was 0.20 with -9.00/-1.50 x 25◦ in the right eye.", + "Her best-corrected distance visual acuity (CDVA) was 0.80 with +4.00 sphere correction in the left eye.", + "Distance visual acuity was measured using a standard Snellen acuity chart at 6m and presented in decimals.", + "Her best corrected near visual acuity (CNVA) was J9 with +2.50.", + "Her best corrected near visual acuity (CNVA) was J1 with +2.50.", + "The Jaeger eye chart was used in testing near vision acuity.", + "Slit-lamp examination revealed incipient cataracts in both eyes.", + "A dilated fundus examination revealed vitreous liquefaction and myopic macula in the right eye.", + "Intraocular pressure (IOP), measured with iCare, was average at 18/19 mmHg.", + "The axial length of the right eye was 27.96 mm.", + "The axial length of the left eye was 22.44 mm.", + "ICL implantation was no option due to the incipient cataract that already existed and the possibility of its progress in the future.", + "We decided on cataract surgery with intraocular lens (IOL) implantation.", + "We decided to implant the Eyhance lens.", + "The Eyhance lens has been designed to improve visual acuity contrast sensitivity and reduce the effects of glare in patients who have undergone cataract surgery.", + "The procedure involved removing the patient’s natural lens and replacing it with the Eyhance lens.", + "After a month, the patient’s best CDVA of the right eye was 0.35.", + "After a month, the patient’s best CDVA of the left eye was 0.95.", + "Near visual acuity improved, with the patient now able to read at J4 for her right eye with +1.50 sphere correction.", + "Near visual acuity improved, with the patient now able to read at J1 for her left eye with +1.50 sphere correction.", + "It’s important to note that cataract surgery carries potential risks and complications." + ], + "summary": "A 58-year-old female patient presented to our clinic complaining of blurry vision in her left eye that had persisted for a year. The patient reported intolerance to contact lenses and a history of amblyopia in her right eye. CDVA was 0.20 with -9.00/-1.50 x 25◦ in her right and 0.80 with +4.00 sphere correction in her left eye, while her CNVA was J9 with +2.50 and J1 with +2.50. Slit-lamp examination revealed early cataracts in both eyes, with otherwise normal findings. A dilated fundus examination showed vitreous liquefaction and myopic macula in the right eye but normal results in both eyes' posterior segments. The IOP was within normal limits, and the eye's axial length was measured. Considering the patient's intolerance to contact lenses, cataract surgery with intraocular lens implantation was deemed appropriate. Given the anisometropic amblyopia, the Eyhance lens was selected to optimize the patient's visual acuity. Following the procedure, the patient's visual acuity improved significantly, with her best CDVA at 0.35 in the right eye and 0.95 in the left eye. With +1.50 sphere correction, the CNVA was also enhanced, with the patient reading at J4 and J1 for her right and left eye, respectively. These improvements may have positively impacted the patient's quality of life and ability to perform daily activities.", + "summary_subclaims": [ + "The patient is a 58-year-old female.", + "The patient reported blurry vision in her left eye that had persisted for a year.", + "The patient reported intolerance to contact lenses.", + "The patient has a history of amblyopia in her right eye.", + "CDVA was 0.20 with -9.00/-1.50 x 25◦ in her right eye.", + "CDVA was 0.80 with +4.00 sphere correction in her left eye.", + "CNVA was J9 with +2.50 in her right eye.", + "CNVA was J1 with +2.50 in her left eye.", + "Slit-lamp examination revealed early cataracts in both eyes.", + "A dilated fundus examination showed vitreous liquefaction in the right eye.", + "A dilated fundus examination showed myopic macula in the right eye.", + "The IOP was within normal limits.", + "The eye's axial length was measured.", + "Cataract surgery with intraocular lens implantation was deemed appropriate.", + "The Eyhance lens was selected.", + "Following the procedure, the patient's best CDVA was 0.35 in the right eye.", + "Following the procedure, the patient's best CDVA was 0.95 in the left eye.", + "With +1.50 sphere correction, the CNVA was J4 in the right eye.", + "With +1.50 sphere correction, the CNVA was J1 in the left eye.", + "These improvements may have positively impacted the patient's quality of life." + ] + }, + { + "id": "multiclinsum_test_1503_en.txt", + "fulltext": "A 55-year-old man (height, 176 cm; weight, 95 kg) with rhegmatogenous retinal detachment presented to the hospital after experiencing sudden blackout of vision in the right eye for over 20 days prior to his visit. He had a medical history of claustrophobia for over 40 years and severe obstructive sleep apnea syndrome (OSAS); however, he had not undergone any treatment. He had no medical history of chronic systemic diseases such as hypertension, diabetes, coronary heart disease, allergies, or surgery. The preoperative physical examination was unremarkable.\nSurgery under local anesthesia was initially planned to take place in an ophthalmic operating room. The first operation failed, as the patient experienced a panic attack upon entering the operation room. The ophthalmologist subsequently applied for anesthesia sedation surgery the next day and consulted the anesthesiology department. After consultation with the anesthesiology department, it was found that the patient had severe OSAS, and thus, the risk of adverse events surrounding surgery under sedation in the ophthalmic operating room was high. As a result, the patient’s safety could not be guaranteed, and general anesthesia surgery was recommended in the anesthesiology operating room. On the day of the surgery, the patient was so resistant to the unfamiliar environment of the anesthesiology operating room that the operation had to be canceled again. After building trust with the patient, the anesthesiologist accompanied the patient to the anesthesiology operating room. However, the patient still experienced a panic attack when he entered the room. He complained of a severe headache, throat obstruction, near suffocation, and an uncontrollable and desperate need to escape the operating room. Neither the nurse nor the doctor could comfort him effectively. Finally, the operation was canceled again. After multidisciplinary consultation, the anesthesiologist recommended that the patient be accompanied by family members for anesthesia sedation outside the operating room of the anesthesiology department, followed by completion of the operation under general anesthesia in the operating room.\nThe patient underwent routine fasting. On the day of the surgery, the patient, accompanied by his family members, went to the hall outside the operating room of the anesthesiology department. He half-laid on the surgical transfer bed, facing a large window in the hall. The patient felt comfortable looking out of the window, and the anesthesiologist relaxed the patient through conversation. After cannulating an upper extremity peripheral vein, intravenous midazolam (3 mg) and propofol (30 mg) were administered for induction, and the patient was quickly transferred to the operating room after he lost consciousness. He was administered high-flow oxygen via mask for FiO2 100%, oxygen flow 6 L/minutes, with routine monitoring of vital signs. Heart rate was 65 beats per minute, blood pressure 112/55 mm Hg, oxygen saturation 100%, temperature 36.5°C, and bispectral index 75. Intravenous injection of etomidate (20 mg), sufentanil (10 μg), and dexmedetomidine hydrochloride infusion (1 μg/kg during the first 10 minutes) were administered. After stabilization of the heart rate and blood pressure, intravenous injection of cis-atracurium (15 mg) was given to complete anesthesia induction. Oxygen was administered via a mask to assist with breathing, and mechanical ventilation was started after oral placement of a No. 4 laryngeal mask following muscle relaxation. Subsequently, intravenous targeted infusion of propofol (3.0–6.0 μg/mL) and remifentanil (2.0–8.0 ng/mL) and an intravenous dexmedetomidine pump were started for intraoperative maintenance of bispectral index 40 to 60. The surgery took 55 minutes. The operation went smoothly, and the intraoperative vital signs were stable. After the operation, the patient was taken to the hall outside the operating room and kept in a supine position facing the window of the hall. The oxygen bag provided oxygen compound air for spontaneous breathing with a heart rate of 55 beats per minute, blood pressure 96/62 mm Hg, and oxygen saturation 100%. After spontaneous breathing with oxygen saturation ≥ 98% under room air, the laryngeal mask was removed once extubation conditions were reached. The patient had no difficulty in breathing after removing the laryngeal mask, and the semi-recumbent position kept the patient’s airway open and comfortable. After 30 minutes of observation, the patient was fully conscious, breathing was completely restored, and he could communicate normally. He was then sent back to the ward, and all his vital signs remained stable after the operation.\nAfter a few days, the patient was interviewed over the telephone. He had returned to his daily routine, and there were no long-term postoperative adverse events. He described having a fear of enclosed spaces that could be traced back to childhood experiences. He said that he could consciously control his emotions before the surgery, but still experienced uncontrollable fear unconsciously during the operation; however, the extra-operative anesthesia and awakening experience were comfortable.\nWritten informed consent for publication of this report was obtained from the patient and his family.", + "fulltext_subclaims": [ + "The patient is a 55-year-old man.", + "The patient's height is 176 cm.", + "The patient's weight is 95 kg.", + "The patient had rhegmatogenous retinal detachment.", + "The patient experienced sudden blackout of vision in the right eye.", + "The blackout of vision occurred over 20 days prior to his visit.", + "The patient had a medical history of claustrophobia for over 40 years.", + "The patient had severe obstructive sleep apnea syndrome.", + "The patient had not undergone any treatment.", + "The patient had no medical history of chronic systemic diseases such as hypertension, diabetes, coronary heart disease, allergies, or surgery.", + "The preoperative physical examination was unremarkable.", + "Surgery under local anesthesia was initially planned.", + "The first operation failed because the patient experienced a panic attack upon entering the operation room.", + "The ophthalmologist applied for anesthesia sedation surgery the next day.", + "The anesthesiology department consultation found that the patient had severe OSAS.", + "The risk of adverse events surrounding surgery under sedation in the ophthalmic operating room was high.", + "General anesthesia surgery was recommended in the anesthesiology operating room.", + "The patient was resistant to the unfamiliar environment of the anesthesiology operating room.", + "The operation had to be canceled again.", + "The anesthesiologist accompanied the patient to the anesthesiology operating room.", + "The patient still experienced a panic attack when he entered the room.", + "The patient complained of a severe headache.", + "The patient complained of throat obstruction.", + "The patient complained of near suffocation.", + "The patient had an uncontrollable and desperate need to escape the operating room.", + "Neither the nurse nor the doctor could comfort him effectively.", + "The operation was canceled again.", + "The anesthesiologist recommended that the patient be accompanied by family members for anesthesia sedation outside the operating room of the anesthesiology department.", + "The patient underwent routine fasting.", + "On the day of the surgery, the patient was accompanied by his family members.", + "The patient went to the hall outside the operating room of the anesthesiology department.", + "The patient half-laid on the surgical transfer bed.", + "The patient faced a large window in the hall.", + "The patient felt comfortable looking out of the window.", + "The anesthesiologist relaxed the patient through conversation.", + "Intravenous midazolam (3 mg) was administered for induction.", + "Intravenous propofol (30 mg) was administered for induction.", + "The patient was quickly transferred to the operating room after he lost consciousness.", + "High-flow oxygen via mask was administered with FiO2 100%.", + "Oxygen flow was 6 L/minutes.", + "Heart rate was 65 beats per minute.", + "Blood pressure was 112/55 mm Hg.", + "Oxygen saturation was 100%.", + "Temperature was 36.5°C.", + "Bispectral index was 75.", + "Intravenous injection of etomidate (20 mg) was administered.", + "Intravenous injection of sufentanil (10 μg) was administered.", + "Dexmedetomidine hydrochloride infusion (1 μg/kg during the first 10 minutes) was started.", + "Intravenous injection of cis-atracurium (15 mg) was given to complete anesthesia induction.", + "Oxygen was administered via a mask to assist with breathing.", + "Mechanical ventilation was started after oral placement of a No. 4 laryngeal mask.", + "Intravenous targeted infusion of propofol (3.0–6.0 μg/mL) was started.", + "Intravenous targeted infusion of remifentanil (2.0–8.0 ng/mL) was started.", + "An intravenous dexmedetomidine pump was started.", + "Intraoperative maintenance of bispectral index 40 to 60 was achieved.", + "The surgery took 55 minutes.", + "The operation went smoothly.", + "The intraoperative vital signs were stable.", + "After the operation, the patient was taken to the hall outside the operating room.", + "The patient was kept in a supine position facing the window.", + "The oxygen bag provided oxygen compound air for spontaneous breathing.", + "Heart rate was 55 beats per minute.", + "Blood pressure was 96/62 mm Hg.", + "Oxygen saturation was 100%.", + "The laryngeal mask was removed once extubation conditions were reached.", + "The patient had no difficulty in breathing after removing the laryngeal mask.", + "The semi-recumbent position kept the patient’s airway open and comfortable.", + "After 30 minutes of observation, the patient was fully conscious.", + "Breathing was completely restored.", + "The patient could communicate normally.", + "The patient was sent back to the ward.", + "All his vital signs remained stable after the operation.", + "After a few days, the patient was interviewed over the telephone.", + "He had returned to his daily routine.", + "There were no long-term postoperative adverse events.", + "He described having a fear of enclosed spaces that could be traced back to childhood experiences.", + "He said that he could consciously control his emotions before the surgery.", + "He still experienced uncontrollable fear unconsciously during the operation.", + "The extra-operative anesthesia and awakening experience were comfortable.", + "Written informed consent for publication of this report was obtained from the patient and his family." + ], + "summary": "We report the case of a 55-year-old man with severe anxiety disorder and claustrophobia who required anesthesia for the surgical treatment of rhegmatogenous retinal detachment. This patient had a history of severe anxiety and claustrophobia for more than 40 years, without having received any treatment for the condition. The patient had failed to tolerate multiple chamber surgeries. Following multidisciplinary discussion, the patient's surgery was performed under general anesthesia in the operating room after the patient underwent induction of anesthesia outside the operating room.", + "summary_subclaims": [ + "The patient is a 55-year-old man.", + "The patient has a severe anxiety disorder.", + "The patient has claustrophobia.", + "The patient required anesthesia for the surgical treatment of rhegmatogenous retinal detachment.", + "The patient had a history of severe anxiety and claustrophobia for more than 40 years.", + "The patient had not received any treatment for the anxiety and claustrophobia.", + "The patient had failed to tolerate multiple chamber surgeries.", + "The patient's surgery was performed under general anesthesia.", + "The patient underwent induction of anesthesia outside the operating room." + ] + }, + { + "id": "multiclinsum_test_2165_en.txt", + "fulltext": "A thirty seven year old female presented with a history of progressive distension of the abdomen with pedal edema and yellow discolouration of the eyes of two weeks duration. On examination she was found to be icteric with an enlarged, firm liver and gross ascites. Liver function tests revealed a conjugated hyperbilirubinemia with mildly deranged transaminases and alkaline phosphatase. Ultrasonography (USG) with Colour Doppler showed an enlarged liver with a hypertrophied caudate lobe, a 1.1 cm portal vein with hepatopetal flow, an occluded right hepatic vein with middle and left hepatic veins patent only in their proximal parts and a patent but narrowed inferior vena cava, compressed by the caudate lobe, together with free fluid in the abdomen. Splenic and superior mesenteric veins were normal. Liver biopsy confirmed the diagnosis of Budd Chiari syndrome. Prothrombotic workup did not reveal any obvious cause for the Budd Chiari syndrome.\nTransjugular venogram showed 90% narrowing of the IVC with a 14 mmHg gradient across the narrowing and non-visualization of the hepatic veins beyond their origins. The hepatic veins could not be cannulated, suggestive of complete occlusion at the ostia. . An 18 × 63 mm WALL STENT was placed across the narrowed segment in the IVC followed by balloon dilatation using a 16 mm balloon .\nPercutaneous transhepatic venogram through the left hepatic vein under USG guidance showed the left hepatic vein was patent only in its proximal portion, the distal 2–3 cms being completely occluded and draining through multiple collaterals. IVC stent was in situ . The right hepatic vein was completely occluded. The middle hepatic vein also showed long-segment total occlusion (> 3 cm).\nRecanalisation of the left hepatic vein was attempted, but failed owing to the long and fibrous nature of the occlusion. The patient then underwent a side-to-side portocaval shunt using the right external iliac vein as H-graft. Postoperative recovery was uneventful and she was anticoagulated during that time. Six weeks after surgery, she was re-admitted with pedal edema and ascites. Doppler evaluation showed patchy flow through the shunt. Venogram through a transjugular approach revealed patent IVC stent. There was narrowing of the portosystemic graft with a gradient of more than 15 mmHg near its IVC end .\nConsidering the acute angulation of the portocaval shunt with the IVC, a transfemoral venous approach for venoplasty and stenting was thought to be more appropriate. Following predilatation of the graft with a 5 mm angioplasty balloon , an 8 mm × 30 mm self-expanding nitinol stent was placed in the graft covering its portal and caval ends. Post dilatation was carried out by a 8 mm balloon. Post stenting portal venogram showed good flow through the graft into the IVC .\nThe portocaval gradient dropped to < 5 mmHg post stenting. Subsequently she was anticoagulated with warfarin. The patient has been on regular follow up since then and is asymptomatic for five years.", + "fulltext_subclaims": [ + "The patient is a thirty seven year old female.", + "She had progressive distension of the abdomen with pedal edema and yellow discolouration of the eyes for two weeks.", + "On examination, she was icteric with an enlarged, firm liver and gross ascites.", + "Liver function tests showed conjugated hyperbilirubinemia.", + "Ultrasonography with Colour Doppler showed an enlarged liver with a hypertrophied caudate lobe.", + "The inferior vena cava was patent but narrowed, compressed by the caudate lobe.", + "Liver biopsy confirmed the diagnosis of Budd Chiari syndrome.", + "Prothrombotic workup did not reveal any obvious cause for the Budd Chiari syndrome.", + "Transjugular venogram showed 90% narrowing of the IVC with a 14 mmHg gradient across the narrowing.", + "The hepatic veins could not be cannulated, suggestive of complete occlusion at the ostia.", + "An 18 × 63 mm WALL STENT was placed across the narrowed segment in the IVC.", + "Percutaneous transhepatic venogram showed the left hepatic vein was patent only in its proximal portion.", + "The right hepatic vein was completely occluded.", + "The middle hepatic vein showed long-segment total occlusion (> 3 cm).", + "Recanalisation of the left hepatic vein was attempted, but failed.", + "The patient underwent a side-to-side portocaval shunt using the right external iliac vein as H-graft.", + "Postoperative recovery was uneventful.", + "Six weeks after surgery, she was re-admitted with pedal edema and ascites.", + "Venogram through a transjugular approach revealed patent IVC stent.", + "There was narrowing of the portosystemic graft with a gradient of more than 15 mmHg near its IVC end.", + "A transfemoral venous approach for venoplasty and stenting was thought to be more appropriate.", + "Following predilatation of the graft with a 5 mm angioplasty balloon, an 8 mm × 30 mm self-expanding nitinol stent was placed in the graft.", + "Post stenting portal venogram showed good flow through the graft into the IVC.", + "The portocaval gradient dropped to < 5 mmHg post stenting.", + "The patient has been on regular follow up since then.", + "The patient is asymptomatic for five years." + ], + "summary": "A 37-year old lady underwent side-to-side portacaval shunt for Budd Chiari syndrome. She had early shunt blockage and this was successfully treated with the placement of a metallic stent across the shunt.", + "summary_subclaims": [ + "The patient is a 37-year old lady.", + "She underwent side-to-side portacaval shunt for Budd Chiari syndrome.", + "She had early shunt blockage.", + "The shunt blockage was successfully treated with the placement of a metallic stent across the shunt." + ] + }, + { + "id": "multiclinsum_test_3092_en.txt", + "fulltext": "18-month-old male infant, the only child of a non-consanguineous couple with no family history of recognized genetic syndromes. His mother, 38 years old at the time of delivery, denied use of medication, as well as smoking or drinking. Routine prenatal examinations were normal, with the exception of the detection of polyhydramnios on the ultrasound of the third trimester. The patient was born by caesarean section at 36 weeks, weighing 2,695 g (0D) associated with microtia grade 3 and an appendix in the trago-oral line on the right. In addition, he presented important suction deficit and respiratory discomfort, remaining on continuous flow of air pressurized in airways by means of CPAP until being submitted to tracheostomy and gastrostomy, with 16 days of life. He was discharged with 38 days of life and with need of supplemental oxygen.\n\nAt 2 months of age, he was referred to the thoracic surgery outpatient department of HC-UFTM for evaluation of stridor and intensification of respiratory discomfort. He underwent naso-fibroscopy, which identified a granuloma just below the tracheostomy orifice, and was submitted to resection. In the same period, he was evaluated by pediatric pneumology and clinical genetics.\n\nThe infant's physical examination revealed hypodevelopment of the facial structures on the right, associated with thoracic kyphoscoliosis, but without the description of epibulbar dermoid. His skull and face CT scan showed agenesis of several structures on the right side of the face, including the upper and lower hemibows, zygomatic arch, masticatory musculature, parotid gland and external auditory canal. No intracranial malformations were found. Urine tract ultrasound was normal, and panoramic radiograph of the spine identified hemivertebrae at the level of T11 and T12, justifying the thoracic deformity. The auditory evoked potential of the brain stem (AEP) confirmed conductive hearing loss in the right ear, and, although there was no heart murmur, the patient underwent a transthoracic echocardiography, which was normal. Finally, the cytogenetic examination with GTG banding, through temporary culture of lymphocytes, and the cytogenomic examination, using the high resolution platform CytoSNP-850®, were normal. The findings of the physical examination combined with the complementary examinations led to the diagnosis of MCF.\n\nThe infant had several visits to the emergency department for nausea, respiratory distress and stridor. At 5 months, he was admitted for investigation of airway obstruction, and a new nasofibroscopy identified a recurrent granuloma, leading to significant tracheal stenosis. The patient underwent granuloma removal again, followed by dilation and exchange of the tracheostomy tube for a longer one to prevent further stenosis.\n\nAbout four months later, the patient presented with a new episode of respiratory discomfort, requiring admission, and was diagnosed with community-acquired pneumonia. On that occasion, he underwent a contrast-enhanced chest CT scan, which showed a trachea with diffusely thickened walls, with a slight reduction in caliber below the end of the tracheostomy cannula; altered pulmonary attenuation, with discrete opacities; and the presence of an aberrant right subclavian artery running posteriorly to the esophagus.\n\nThe infant underwent surgery for ligation and disconnection of the vascular ring caused by the aberrant right subclavian artery at 22 months of age. No other thoracic malformations were described during the surgical procedure. His postoperative course was uneventful, and his mother reported that after the surgical treatment, she has not observed episodes of nausea, or even stridor or respiratory discomfort. The patient is currently being followed by a multidisciplinary team, with good motor progression and awaiting reevaluation for craniofacial surgery.\n", + "fulltext_subclaims": [ + "The patient is an 18-month-old male infant.", + "The parents are a non-consanguineous couple.", + "There is no family history of recognized genetic syndromes.", + "The mother was 38 years old at the time of delivery.", + "The mother denied use of medication, as well as smoking or drinking.", + "Routine prenatal examinations were normal.", + "Polyhydramnios was detected on the ultrasound of the third trimester.", + "The patient was born by caesarean section at 36 weeks.", + "The birth weight was 2,695 g.", + "The birth length was 48 cm.", + "The Apgar score was 8/9.", + "The initial evaluation of the newborn detected important facial asymmetry.", + "The facial asymmetry was associated with microtia grade 3 on the right.", + "An appendix was found in the trago-oral line on the right.", + "The patient had an important suction deficit.", + "The patient had respiratory discomfort.", + "The patient remained on CPAP until being submitted to tracheostomy and gastrostomy.", + "The tracheostomy and gastrostomy were performed at 16 days of life.", + "The patient was discharged at 38 days of life.", + "The patient required supplemental oxygen.", + "At 2 months of age, the patient was referred to the thoracic surgery outpatient department.", + "The referral was for evaluation of stridor and intensification of respiratory discomfort.", + "Naso-fibroscopy identified a granuloma just below the tracheostomy orifice.", + "The patient underwent resection of the granuloma.", + "The patient was evaluated by pediatric pneumology.", + "The patient was evaluated by clinical genetics.", + "The physical examination revealed hypodevelopment of the facial structures on the right.", + "The physical examination revealed thoracic kyphoscoliosis.", + "The skull and face CT scan showed agenesis of several structures on the right side of the face.", + "The CT scan showed agenesis of the upper and lower hemibows on the right.", + "The CT scan showed agenesis of the zygomatic arch on the right.", + "The CT scan showed agenesis of the masticatory musculature on the right.", + "The CT scan showed agenesis of the parotid gland on the right.", + "The CT scan showed agenesis of the external auditory canal on the right.", + "No intracranial malformations were found.", + "The urine tract ultrasound was normal.", + "The panoramic radiograph of the spine identified hemivertebrae at the level of T11 and T12.", + "The AEP confirmed conductive hearing loss in the right ear.", + "The patient underwent a transthoracic echocardiography.", + "The echocardiography was normal.", + "The cytogenetic examination with GTG banding was normal.", + "The cytogenomic examination using the CytoSNP-850® platform was normal.", + "The findings led to the diagnosis of MCF.", + "The patient had several visits to the emergency department for nausea, respiratory distress, and stridor.", + "At 5 months, the patient was admitted for investigation of airway obstruction.", + "A new nasofibroscopy identified a recurrent granuloma.", + "The granuloma led to significant tracheal stenosis.", + "The patient underwent granuloma removal again.", + "The patient underwent dilation.", + "The tracheostomy tube was exchanged for a longer one.", + "Four months later, the patient presented with a new episode of respiratory discomfort.", + "The patient was admitted and diagnosed with community-acquired pneumonia.", + "A contrast-enhanced chest CT scan showed a trachea with diffusely thickened walls.", + "The CT scan showed a slight reduction in caliber below the end of the tracheostomy cannula.", + "The CT scan showed altered pulmonary attenuation with discrete opacities.", + "The CT scan showed the presence of an aberrant right subclavian artery.", + "The aberrant right subclavian artery ran posteriorly to the esophagus.", + "The patient underwent surgery for ligation and disconnection of the vascular ring.", + "The surgery was performed at 22 months of age.", + "No other thoracic malformations were described during the surgical procedure.", + "The postoperative course was uneventful.", + "The mother reported no episodes of nausea, stridor, or respiratory discomfort after the surgical treatment.", + "The patient is currently being followed by a multidisciplinary team.", + "The patient has good motor progression.", + "The patient is awaiting reevaluation for craniofacial surgery." + ], + "summary": "Male infant, 18 months old and the only child of a non-consanguineous couple. At birth, craniofacial dysmorphies (facial asymmetry, maxillary and mandibular hypoplasia, macrostomia, microtia grade 3 and appendage in the trago-oral line) were observed restricted to the right side of the face. Complementary examinations evidenced asymmetrical hypoplasia of the face and thoracic hemi-vertebrae. No cytogenetic or cytogenomic abnormalities were identified. The patient developed several episodes of respiratory discomfort, stridor and nausea, even though he had undergone gastrostomy and tracheostomy in the neonatal period. The investigation directed to the respiratory symptoms identified the compression of the esophagus and trachea by an aberrant right subclavian artery. After the surgical correction of this anomaly, the infant has not presented respiratory symptoms and maintains multidisciplinary follow-up seeking rehabilitation.\n", + "summary_subclaims": [ + "The patient is an 18-month-old male infant.", + "The patient is the only child of a non-consanguineous couple.", + "At birth, craniofacial dysmorphies were observed restricted to the right side of the face.", + "Craniofacial dysmorphies included facial asymmetry, maxillary and mandibular hypoplasia, macrostomia, microtia grade 3, and an appendage in the trago-oral line.", + "Complementary examinations evidenced asymmetrical hypoplasia of the face.", + "Complementary examinations also showed thoracic hemi-vertebrae.", + "No cytogenetic or cytogenomic abnormalities were identified.", + "The patient developed several episodes of respiratory discomfort.", + "The patient developed stridor.", + "The patient developed nausea.", + "The patient had undergone gastrostomy in the neonatal period.", + "The patient had undergone tracheostomy in the neonatal period.", + "The investigation directed to the respiratory symptoms identified the compression of the esophagus and trachea by an aberrant right subclavian artery.", + "After the surgical correction of this anomaly, the infant has not presented respiratory symptoms.", + "The infant maintains multidisciplinary follow-up seeking rehabilitation." + ] + }, + { + "id": "multiclinsum_test_1597_en.txt", + "fulltext": "A 67-year-old man who was a current smoker presented with an edematous right arm and face in our hospital. A chest computed tomography (CT) scan revealed a tumor of approximately 40 mm in diameter in the right upper lobe, with right axial and mediastinal lymph node metastases, and pleural effusion . According to the findings of a transbronchial lung biopsy and systemic survey, he was diagnosed with adenocarcinoma corresponding to clinical T4N3M1c (stage IVB: 8th edition of UICC TNM staging). An epidermal growth factor receptor mutation and rearranged anaplastic lymphoma kinase genes were not detected. His tumor had invaded the superior vena cava (SVC), leading to the swelling of his right arm and face, suggesting SVC syndrome. He was treated with palliative radiotherapy consisting of a total dose of 30 Gy for SVC syndrome. After irradiation, the size of the tumor in the right upper lobe was slightly decreased . Immunohistochemistry using the 22C-3 antibody revealed the high expression of PD-L1 and a TPS of 75%. He did not have a personal or family history of any autoimmune conditions and autoimmune related antibodies such as anti Jo-1 antibody, anti-thyroid peroxidase antibody, anti-thyroid stimulating hormone antibody, free T3, free T4, rheumatoid factor (RF), anti-acetylcholine receptor antibody, antinuclear antibody and anti-glutamic acid decarboxylase antibody did not show abnormal findings. Subsequently, pembrolizumab (200 mg/body, every 3 weeks) was initiated as the first-line therapy. Approximately 2.5 months after treatment with pembrolizumab, he presented with an asymptomatic, poorly demarcated 1–3 cm erythematous plaque over the right trunk of his body, which gradually developed in size . He had no symptoms and his blood examination test results showed no remarkable changes. Therefore, pembrolizumab therapy was continued. Histopathologic examination from a skin biopsy showed ectatic dermal lymphatics with intraluminal aggregations of histiocytes , which were positive for CD68 and lymphatic vessels that were positive for podoplanin (D2–40) . We ultimately diagnosed him as ILH based on the clinical and histopathological findings. RF and anti-cyclic citrullinated peptide (CCP) antibody were checked after the appearance of erythematous plaques; however, they were negative. Laboratory results revealed that TNF-α levels were increased after 2 months of pembrolizumab treatment . After 4 cycles of pembrolizumab treatment, the size of the tumor in right upper lobe had decreased. However, the tumor in the axial lymph node progressed and his right arm swelling worsened. Therefore, the treatment was changed to cisplatin (75 mg/m2) and pemetrexed (500 mg/m2) as second-line therapy. After 2 cycles of chemotherapy, he maintained a partial response without any severe adverse events and ILH was gradually resolved with topical steroid therapy.", + "fulltext_subclaims": [ + "A 67-year-old man who was a current smoker presented with an edematous right arm and face in our hospital.", + "A chest computed tomography (CT) scan revealed a tumor of approximately 40 mm in diameter in the right upper lobe.", + "The chest CT scan showed right axial and mediastinal lymph node metastases.", + "The chest CT scan showed pleural effusion.", + "He was diagnosed with adenocarcinoma corresponding to clinical T4N3M1c (stage IVB: 8th edition of UICC TNM staging).", + "An epidermal growth factor receptor mutation was not detected.", + "A rearranged anaplastic lymphoma kinase gene was not detected.", + "His tumor had invaded the superior vena cava (SVC).", + "He was treated with palliative radiotherapy consisting of a total dose of 30 Gy for SVC syndrome.", + "After irradiation, the size of the tumor in the right upper lobe was slightly decreased.", + "Immunohistochemistry using the 22C-3 antibody revealed the high expression of PD-L1.", + "The tumor had a TPS of 75%.", + "He did not have a personal or family history of any autoimmune conditions.", + "Autoimmune related antibodies such as anti Jo-1 antibody, anti-thyroid peroxidase antibody, anti-thyroid stimulating hormone antibody, free T3, free T4, rheumatoid factor (RF), anti-acetylcholine receptor antibody, antinuclear antibody and anti-glutamic acid decarboxylase antibody did not show abnormal findings.", + "Pembrolizumab (200 mg/body, every 3 weeks) was initiated as the first-line therapy.", + "Approximately 2.5 months after treatment with pembrolizumab, he presented with an asymptomatic, poorly demarcated 1–3 cm erythematous plaque over the right trunk of his body.", + "The erythematous plaque gradually developed in size.", + "He had no symptoms.", + "His blood examination test results showed no remarkable changes.", + "Pembrolizumab therapy was continued.", + "Histopathologic examination from a skin biopsy showed ectatic dermal lymphatics with intraluminal aggregations of histiocytes.", + "The histiocytes were positive for CD68.", + "The lymphatic vessels were positive for podoplanin (D2–40).", + "We ultimately diagnosed him as ILH based on the clinical and histopathological findings.", + "RF and anti-cyclic citrullinated peptide (CCP) antibody were checked after the appearance of erythematous plaques.", + "RF and anti-cyclic citrullinated peptide (CCP) antibody were negative.", + "Laboratory results revealed that TNF-α levels were increased after 2 months of pembrolizumab treatment.", + "After 4 cycles of pembrolizumab treatment, the size of the tumor in right upper lobe had decreased.", + "The tumor in the axial lymph node progressed.", + "His right arm swelling worsened.", + "The treatment was changed to cisplatin (75 mg/m2) and pemetrexed (500 mg/m2) as second-line therapy.", + "After 2 cycles of chemotherapy, he maintained a partial response without any severe adverse events.", + "ILH was gradually resolved with topical steroid therapy." + ], + "summary": "We present a 67-year-old man with lung adenocarcinoma who developed ILH associated with pembrolizumab treatment. He was treated with palliative thoracic radiotherapy for superior vena cava syndrome. Subsequently, he received four cycles of pembrolizumab. Approximately 2.5 months after the initiation of pembrolizumab, he developed erythema on the trunk of his body. Based on findings of skin biopsies, he was diagnosed with pembrolizumab-induced ILH. Moreover, the upregulation of tumor necrosis factor-α was observed during pembrolizumab therapy.", + "summary_subclaims": [ + "The patient is a 67-year-old man with lung adenocarcinoma.", + "The patient developed ILH associated with pembrolizumab treatment.", + "He was treated with palliative thoracic radiotherapy for superior vena cava syndrome.", + "He received four cycles of pembrolizumab.", + "Approximately 2.5 months after the initiation of pembrolizumab, he developed erythema on the trunk of his body.", + "Based on findings of skin biopsies, he was diagnosed with pembrolizumab-induced ILH.", + "The upregulation of tumor necrosis factor-α was observed during pembrolizumab therapy." + ] + }, + { + "id": "multiclinsum_test_2491_en.txt", + "fulltext": "A 42-year-old male complained of recurrent episodes of melena and dizziness, fatigue and reduced exercise capacity for more than 2 mo.\nThe patient's symptoms started 2 mo ago with recurrent episodes of melena and he frequently felt fatigued. He was diagnosed with a gastric ulcer and anemia after undergoing gastroduodenoscopy, colonoscopy and laboratory blood tests. Then he took oral proton-pump inhibitors and iron for 1.5 mo, but these therapies did not ameliorate the symptoms.\nThe patient had no previous medical history.\nOn examination, anemic face and upper abdominal tenderness were noted. The vital signs were normal with a respiratory rate of 18/min, heart rate of 96/min and blood pressure of 102/62 mmHg.\nBlood analysis revealed severe iron-deficiency anemia with hemoglobin of 53 g/dL, and fecal occult blood was positive. Blood biochemistry, tumor biomarkers, other blood tests as well as urine analysis were normal. Electrocardiogram and chest X-ray were also normal.\nWhen the patient presented in our hospital, two units of blood were transfused. The gastroduodenoscopy was performed again. A sealed ulcer without any signs of bleeding sign were found in the antrum. We then performed a CE. Bleeding was found in the jejunum after running the capsule for 97 min. The total running time in the small bowel was about 300 min. The CE cannot determine the cause of bleeding due to the short stay around the lesion and the influence of the blood. An anterograde BAE was performed, and a protruded lesion was revealed in the jejunum at about 150 cm distal to the ligament of Treitz. It filled half of the intestinal cavity. The tumor was lobulated with white patches on the mucosal surface with blood oozing in the fundus . Multiple biopsies were taken, and pathological findings further revealed that hyperplastic thin-walled lymphatic and venous with luminal dilation presented in the submucosal area .", + "fulltext_subclaims": [ + "The patient is a 42-year-old male.", + "He complained of recurrent episodes of melena.", + "He had dizziness, fatigue, and reduced exercise capacity for more than 2 mo.", + "The patient's symptoms started 2 mo ago with recurrent episodes of melena.", + "He frequently felt fatigued.", + "He was diagnosed with a gastric ulcer.", + "He was diagnosed with anemia.", + "He underwent gastroduodenoscopy.", + "He underwent colonoscopy.", + "He had laboratory blood tests.", + "He took oral proton-pump inhibitors.", + "He took iron for 1.5 mo.", + "These therapies did not ameliorate the symptoms.", + "The patient had no previous medical history.", + "Anemic face was noted on examination.", + "Upper abdominal tenderness was noted on examination.", + "The respiratory rate was 18/min.", + "The heart rate was 96/min.", + "The blood pressure was 102/62 mmHg.", + "Blood analysis revealed severe iron-deficiency anemia.", + "Hemoglobin was 53 g/dL.", + "Fecal occult blood was positive.", + "Blood biochemistry was normal.", + "Tumor biomarkers were normal.", + "Other blood tests were normal.", + "Urine analysis was normal.", + "Electrocardiogram was normal.", + "Chest X-ray was normal.", + "Two units of blood were transfused.", + "Gastroduodenoscopy was performed again.", + "A sealed ulcer without any signs of bleeding was found in the antrum.", + "A CE was performed.", + "Bleeding was found in the jejunum after running the capsule for 97 min.", + "The total running time in the small bowel was about 300 min.", + "The CE cannot determine the cause of bleeding due to the short stay around the lesion and the influence of the blood.", + "An anterograde BAE was performed.", + "A protruded lesion was revealed in the jejunum at about 150 cm distal to the ligament of Treitz.", + "The tumor filled half of the intestinal cavity.", + "The tumor was lobulated with white patches on the mucosal surface.", + "Blood oozing was present in the fundus.", + "Multiple biopsies were taken.", + "Pathological findings revealed hyperplastic thin-walled lymphatic and venous with luminal dilation in the submucosal area." + ], + "summary": "A 42-year-old male complained of recurrent episodes of melena and dizziness, fatigue and reduced exercise capacity for more than 2 mo. Gastroduodenoscopy and blood test revealed a gastric ulcer and anemia. Treatment with oral proton-pump inhibitors and iron did not improve symptoms. We then performed a capsule endoscopy and anterograde balloon-assisted enteroscopy and revealed a hemolymphangioma. Considering it is a benign tumor without malignant potential, we performed enteroscopic injection sclerotherapy. He was discharged 4 days later. At follow-up 3 mo later, the melena disappeared. Balloon-assisted enteroscopy revealed an atrophied tumor atrophied and no bleeding. Argon plasma coagulation was applied to the surface of the hemolymphangioma to accelerated healing. When he returned for follow-up 1 year later, anemia was resolved and the tumor had been cured.", + "summary_subclaims": [ + "The patient is a 42-year-old male.", + "The patient complained of recurrent episodes of melena.", + "The patient reported dizziness.", + "The patient had fatigue.", + "The patient had reduced exercise capacity for more than 2 mo.", + "Gastroduodenoscopy and blood test revealed a gastric ulcer.", + "Gastroduodenoscopy and blood test revealed anemia.", + "Treatment with oral proton-pump inhibitors and iron did not improve symptoms.", + "A capsule endoscopy was performed.", + "An anterograde balloon-assisted enteroscopy was performed.", + "A hemolymphangioma was revealed.", + "The hemolymphangioma is a benign tumor.", + "The hemolymphangioma has no malignant potential.", + "Enteroscopic injection sclerotherapy was performed.", + "The patient was discharged 4 days later.", + "At follow-up 3 mo later, the melena disappeared.", + "Balloon-assisted enteroscopy revealed an atrophied tumor.", + "Balloon-assisted enteroscopy revealed no bleeding.", + "Argon plasma coagulation was applied to the surface of the hemolymphangioma.", + "Argon plasma coagulation was applied to accelerate healing.", + "At follow-up 1 year later, anemia was resolved.", + "At follow-up 1 year later, the tumor had been cured." + ] + }, + { + "id": "multiclinsum_test_54_en.txt", + "fulltext": "A 60-year-old man was admitted to our hospital with complaints of difficulty in swallowing and left chest pain.\nThe patient had a 6-month history of persistent, worsening difficulty in swallowing since December 2023.\nThe patient had no significant history.\nMother of the patient had the history of uterine cancer.\nThe patient showed a poor general condition, with Eastern Comprehensive Oncology Group Performance Status (ECOG PS 3).\nBlood tests showed preserved bone marrow, liver, and kidney functions, without coagulation abnormalities. Serum levels of tumor markers (carcinoembryonic antigen, SCC) were not increased.\nUpper gastrointestinal endoscopy showed a submucosal tumor-like protruding lesion, occupying nearly the entire lumen from the mid to lower thoracic esophagus, causing stenosis . Contrast-enhanced computed tomography (CT) showed esophageal tumor invasion into the left atrium, multiple liver and lung metastases, and a left pleural effusion . The biopsy specimen of the esophageal tumor showed spindle cells, positive for the mesenchymal marker vimentin and negative for epithelial markers including AE1/AE3, CAM5.2, p40, and cytokeratin 7, leading to a suspicion of esophageal sarcoma, and the patient was referred to our hospital for treatment. Cardiac ultrasonography showed a tumorous lesion on the posterior side of the left atrium, however, no invasion into the heart or intramyocardial tumor was observed. Chest X-ray and ultrasonography showed a pleural effusion, and thoracentesis was performed to alleviate symptoms and make a diagnosis, draining 1000 mL of slightly turbid, bloody pleural fluid. However, chest X-ray the next day showed re-accumulation of pleural fluid to the same degree as before drainage. Upper gastrointestinal endoscopy allowed passage of a slim scope, and biopsy of the primary lesion was performed. Histopathologically, atypical spindle cells and polymorphic cells, however, no epithelial components, were observed and immunohistological staining was negative for AE1/AE3, CAM5.2, cytokeratin 5/6, and p63, similar to the previous pathological report; thus, an epithelial malignant tumor could not be confirmed. The programmed death-ligand 1 Combined Positive Score (CPS) was ≥ 10. Pleural fluid cytology showed malignant cells, and cell block immunostaining showed similar findings to those of the primary lesion. Cancer stem cell markers including ZEB1 and TWIST were positive in both the primary and metastatic cardiac lesions .", + "fulltext_subclaims": [ + "The patient was admitted with complaints of difficulty in swallowing and left chest pain.", + "The patient had a 6-month history of persistent, worsening difficulty in swallowing since December 2023.", + "The patient had no significant history.", + "The mother of the patient had a history of uterine cancer.", + "The patient showed a poor general condition, with ECOG PS 3.", + "Blood tests showed preserved bone marrow, liver, and kidney functions, without coagulation abnormalities.", + "Serum levels of tumor markers (carcinoembryonic antigen, SCC) were not increased.", + "Upper gastrointestinal endoscopy showed a submucosal tumor-like protruding lesion, occupying nearly the entire lumen from the mid to lower thoracic esophagus, causing stenosis.", + "Contrast-enhanced CT showed esophageal tumor invasion into the left atrium.", + "Contrast-enhanced CT showed multiple liver and lung metastases.", + "Contrast-enhanced CT showed a left pleural effusion.", + "The biopsy specimen of the esophageal tumor showed spindle cells, positive for the mesenchymal marker vimentin.", + "The biopsy specimen of the esophageal tumor showed negative for epithelial markers including AE1/AE3, CAM5.2, p40, and cytokeratin 7.", + "The biopsy specimen led to a suspicion of esophageal sarcoma.", + "Cardiac ultrasonography showed a tumorous lesion on the posterior side of the left atrium.", + "Chest X-ray and ultrasonography showed a pleural effusion.", + "Thoracentesis was performed, draining 1000 mL of slightly turbid, bloody pleural fluid.", + "Chest X-ray the next day showed re-accumulation of pleural fluid to the same degree as before drainage.", + "Upper gastrointestinal endoscopy allowed passage of a slim scope.", + "Biopsy of the primary lesion was performed.", + "Histopathologically, atypical spindle cells and polymorphic cells were observed.", + "Histopathologically, no epithelial components were observed.", + "Immunohistological staining was negative for AE1/AE3, CAM5.2, cytokeratin 5/6, and p63.", + "An epithelial malignant tumor could not be confirmed.", + "The programmed death-ligand 1 Combined Positive Score (CPS) was ≥ 10.", + "Pleural fluid cytology showed malignant cells.", + "Cell block immunostaining showed similar findings to those of the primary lesion.", + "Cancer stem cell markers including ZEB1 and TWIST were positive in both the primary and metastatic cardiac lesions." + ], + "summary": "The case of a 60-year-old man who complained of dysphagia is presented. Upper gastrointestinal endoscopy showed a submucosal tumor-like elevated lesion in the esophagus causing stenosis. Contrast-enhanced computed tomography showed left atrial compression due to the esophageal tumor, multiple liver and lung metastases, and a left pleural effusion. Pathological examination of a biopsy specimen from the esophageal tumor showed spindle-shaped cells, raising suspicion of esophageal sarcoma. The disease progressed rapidly, and systemic chemotherapy was deemed necessary, however, due to his poor general condition, administration of cytotoxic agents was considered difficult. Given his high Combined Positive Score, nivolumab was administered, however, the patient soon died from the disease. The autopsy confirmed spindle cell carcinoma (SCC) of the esophagus and cardiac metastasis with similar histological features. Cancer stem cell markers, ZEB1 and TWIST, were positive in both the primary tumor and the cardiac metastasis.", + "summary_subclaims": [ + "The patient was a 60-year-old man.", + "The patient complained of dysphagia.", + "Upper gastrointestinal endoscopy showed a submucosal tumor-like elevated lesion in the esophagus.", + "The lesion caused stenosis.", + "Contrast-enhanced computed tomography showed left atrial compression due to the esophageal tumor.", + "Contrast-enhanced computed tomography showed multiple liver and lung metastases.", + "Contrast-enhanced computed tomography showed a left pleural effusion.", + "Pathological examination of a biopsy specimen from the esophageal tumor showed spindle-shaped cells.", + "The disease progressed rapidly.", + "Systemic chemotherapy was deemed necessary.", + "Administration of cytotoxic agents was considered difficult due to his poor general condition.", + "Given his high Combined Positive Score, nivolumab was administered.", + "The patient soon died from the disease.", + "The autopsy confirmed spindle cell carcinoma of the esophagus.", + "The autopsy confirmed cardiac metastasis with similar histological features.", + "Cancer stem cell markers, ZEB1 and TWIST, were positive in both the primary tumor and the cardiac metastasis." + ] + }, + { + "id": "multiclinsum_test_1839_en.txt", + "fulltext": "A 25-year-old Caucasian female with a history of type 1 neurofibromatosis was brought to our hospital with diffuse abdominal pain, nausea, vomiting and fever following cesarean section for fetal distress. She was transferred to our institution within 18 hours of the onset of symptoms for surgical intervention in view of the ominous findings on computed tomography (CT) scan and endoscopy done at the peripheral hospital. She had not passed flatus or stool since surgery and denied hemetemesis, melena, shortness of breath, or chest pain. There was no history of tobacco or alcohol abuse, ingestion of corrosive substances or non-steroidal anti inflammatory drugs (NSAIDs).\nOur patient appeared acutely ill and toxic. She had a temperature of 38.8°C, pulse of 120/min, blood pressure of 154/90 mmHg, respiratory rate of 24/min, and oxygen saturation of 97% on 2 L of oxygen. The cardiac and respiratory exams were otherwise unremarkable. Her abdomen was markedly distended. There was diffuse tenderness on palpation of the abdomen with no peritoneal signs. The cesarean section incision appeared clean with no tenderness or discharge. Bowel sounds were absent on auscultation. There were multiple neurofibromas on our patient's neck and anterior chest consistent with her diagnosis of neurofibromatosis. Her white blood cell count was 25,000/mm3, with 91% neutrophils. The initial electrolytes, amylase, lipase and liver function tests were within normal limits.\nCT scan of our patient's abdomen showed marked gastric dilation and air in the wall of the stomach along the entire greater curvature and portal venous system . There was marked dilatation of the small and large bowel. Esophagogastroduodenoscopy (EGD) of our patient showed areas of diffuse mucosal congestion and extreme pallor as well as ulceration on the posterior wall and greater curvature of the stomach. Gastric biopsy revealed transmural necrosis. Streptococcus viridans was isolated from gastric biopsy. Blood cultures did not grow any pathogenic bacteria and nasogastric cultures were not obtained.\nOur patient was diagnosed with emphysematous gastritis and promptly started on intravenous clindamycin and piperacillin/tazobactam, nasogastric decompression and intravenous hydration. Total parenteral nutrition was initiated from day two and our patient was closely monitored in the intensive care unit for three days. She improved with the above measures and tube feedings were initiated from day seven. Follow-up CT scan on day eight showed resolution of the gastric and portal venous air . Our patient was finally discharged home on oral proton pump inhibitors on day 10. A follow-up EGD two months later showed no sequelae and our patient remained asymptomatic.", + "fulltext_subclaims": [ + "The patient is a 25-year-old Caucasian female.", + "She has a history of type 1 neurofibromatosis.", + "She was brought to the hospital with diffuse abdominal pain, nausea, vomiting, and fever.", + "The symptoms began after a cesarean section for fetal distress.", + "She was transferred within 18 hours of symptom onset.", + "The transfer was for surgical intervention.", + "Computed tomography (CT) scan and endoscopy were done at the peripheral hospital.", + "The CT scan and endoscopy findings were ominous.", + "She had not passed flatus or stool since surgery.", + "She denied hemetemesis, melena, shortness of breath, or chest pain.", + "There was no history of tobacco or alcohol abuse.", + "There was no ingestion of corrosive substances.", + "There was no ingestion of non-steroidal anti-inflammatory drugs (NSAIDs).", + "She appeared acutely ill and toxic.", + "Her temperature was 38.8°C.", + "Her pulse was 120/min.", + "Her blood pressure was 154/90 mmHg.", + "Her respiratory rate was 24/min.", + "Her oxygen saturation was 97% on 2 L of oxygen.", + "The abdomen was markedly distended.", + "There was diffuse tenderness on palpation.", + "There were no peritoneal signs.", + "The cesarean section incision appeared clean.", + "There was no tenderness or discharge from the incision.", + "Bowel sounds were absent.", + "There were multiple neurofibromas on her neck and anterior chest.", + "Her white blood cell count was 25,000/mm3.", + "The white blood cell count was 91% neutrophils.", + "Initial electrolytes were within normal limits.", + "Initial amylase, lipase, and liver function tests were within normal limits.", + "CT scan showed marked gastric dilation.", + "CT scan showed air in the wall of the stomach along the entire greater curvature.", + "CT scan showed air in the portal venous system.", + "CT scan showed marked dilatation of the small and large bowel.", + "Esophagogastroduodenoscopy showed areas of diffuse mucosal congestion.", + "Esophagogastroduodenoscopy showed extreme pallor.", + "Esophagogastroduodenoscopy showed ulceration on the posterior wall and greater curvature of the stomach.", + "Gastric biopsy revealed transmural necrosis.", + "Streptococcus viridans was isolated from gastric biopsy.", + "Blood cultures did not grow any pathogenic bacteria.", + "The patient was diagnosed with emphysematous gastritis.", + "She was started on intravenous clindamycin.", + "She was started on intravenous piperacillin/tazobactam.", + "Nasogastric decompression was initiated.", + "Intravenous hydration was initiated.", + "Total parenteral nutrition was initiated from day two.", + "She was monitored in the intensive care unit for three days.", + "She improved with the above measures.", + "Tube feedings were initiated from day seven.", + "Follow-up CT scan on day eight showed resolution of gastric and portal venous air.", + "She was discharged home on day 10.", + "She was discharged on oral proton pump inhibitors.", + "A follow-up EGD two months later showed no sequelae.", + "The patient remained asymptomatic." + ], + "summary": "A 25-year-old Caucasian woman with neurofibromatosis type 1 presented to our hospital with diffuse abdominal pain immediately after a cesarean section. The patient was acutely ill and toxic with a fever of 38.8 degrees C, a pulse of 120 beats per minute and a distended abdomen with absent bowel sounds. A computed tomography scan showed air in the wall of the stomach and portal venous system. The patient was successfully treated with intravenous antibiotics, bowel rest and total parenteral nutrition.", + "summary_subclaims": [ + "The patient is a 25-year-old Caucasian woman.", + "The patient has neurofibromatosis type 1.", + "The patient presented with diffuse abdominal pain immediately after a cesarean section.", + "The patient was acutely ill and toxic.", + "The patient had a fever of 38.8 degrees C.", + "The patient had a pulse of 120 beats per minute.", + "The patient had a distended abdomen.", + "The patient had absent bowel sounds.", + "A computed tomography scan showed air in the wall of the stomach.", + "A computed tomography scan showed air in the portal venous system.", + "The patient was treated with intravenous antibiotics.", + "The patient was treated with bowel rest.", + "The patient was treated with total parenteral nutrition." + ] + }, + { + "id": "multiclinsum_test_1215_en.txt", + "fulltext": "A-39-year old Chinese man was admitted to our hospital for repeated oral ulcers and headaches for 8 years, chest pain for 7 months. He had no diabetes, no relevant medical family history, and no external genital ulcer. The laboratory test results: C-reactive protein of 32.3 mg/L (normal value:<5 mg/L), anti-nuclear antibody (ANA) was positive (normal value: negative), ESR of 55 mg/h (normal value: male: 0-15 ml/h, female: 0-20 ml/h). Transthoracic echocardiography (TTE) demonstrated: aortic sinus was 35 × 57 mm, ascending aorta diameter was 37 mm, at the junction of right and left coronary sinus there was a 12 × 14 mm cystic structure was formed outside from aortic wall, and a 40 × 23 mm cystic structure was formed at the junction of orifice of coronary sinus, as shown in Fig. . CTA scan indicated that the aortic sinus was outwards, the large cross-section area about 4.4 cm × 2.6 cm, as shown in Fig. . After admission to the hospital, he was treated with Glucocorticoid, Thalidomide, and Atorvastatin in the rheumatic immunology department until the inflammatory markers returned to a normal level, then he received modified Bentall surgery and continue to take medicine as pre-operation. After 8 months follow-up, the patient recovered well: TTE indicated artificial blood vessel has no apparent abnormalities and artificial heart valve is functioning well, no perivalvular leakage (PVL), eject fraction is 62%.\nSurgery process: median sternotomy and establish total cardiopulmonary bypass (CPB), myocardial protection with cold blood cardioplegia. Open the ascend aorta, cut the brachiocephalic artery, the native root including the annulus was excised, aortic root replacement with the modified Bentall technique was performed: The valved conduit procedure was a modified Bentall operation where the aortic mechanical valve prosthesis was sutured into the graft at 1 cm from the end of the graft with a continuous 3–0 polypropylene suture, forming a composite graft, which was directly sutured to the left ventricular outflow tract with a continuous 3–0 polypropylene suture other than to annulus, and then the composite graft was fixed by outside the aortic wall with a belt-like Teflon felt. The coronary buttons were anastomosed to the composite valve graft end-to-side with continuous suture used a 5–0 polypropylene suture without any tension, at last, the distal end of the conduit was anastomosed to the distal ascending aorta with continuous 3–0 polypropylene sutures. The CPB and aortic cross-clamp times were 117 min and 60 min respectively. During this procedure no difficult bleeding encountered. There was no obvious abnormality in the function of artificial mechanical valves, and artificial ascending aortic blood flow was smooth, TEE suggested the aortic valve mechanical valve worked well, as shown in Fig. . Postoperative pathological indicated that the inner layer of the arterial wall was uneven, with partial fibrous hyperplasia, focal mucus degeneration, and a few lymphocytes infiltration. Immunohistochemical: smooth muscle cells were positive, CD3 + lymphocyte infiltration. Web dyeing: elastic fibers were positive, which suggested aseptic inflammatory changes in the aorta.", + "fulltext_subclaims": [ + "The patient is a 39-year-old Chinese man.", + "He had repeated oral ulcers and headaches for 8 years.", + "He had chest pain for 7 months.", + "He had no diabetes.", + "He had no relevant medical family history.", + "He had no external genital ulcer.", + "C-reactive protein was 32.3 mg/L.", + "The normal value for C-reactive protein is <5 mg/L.", + "Anti-nuclear antibody (ANA) was positive.", + "The normal value for ANA is negative.", + "ESR was 55 mg/h.", + "The normal value for ESR in males is 0-15 ml/h.", + "Transthoracic echocardiography demonstrated a 12 × 14 mm cystic structure at the junction of right and left coronary sinus.", + "Transthoracic echocardiography demonstrated a 40 × 23 mm cystic structure at the junction of the orifice of the coronary sinus.", + "CTA scan indicated the aortic sinus was outwards.", + "CTA scan indicated the large cross-section area was about 4.4 cm × 2.6 cm.", + "He was treated with Glucocorticoid.", + "He was treated with Thalidomide.", + "He was treated with Atorvastatin.", + "He received modified Bentall surgery.", + "After 8 months follow-up, TTE indicated the artificial blood vessel had no apparent abnormalities.", + "After 8 months follow-up, the artificial heart valve was functioning well.", + "After 8 months follow-up, there was no perivalvular leakage.", + "After 8 months follow-up, the ejection fraction was 62%.", + "The surgery process included median sternotomy.", + "Total cardiopulmonary bypass was established.", + "Myocardial protection was with cold blood cardioplegia.", + "The native root including the annulus was excised.", + "Aortic root replacement was performed with the modified Bentall technique.", + "The valved conduit procedure was a modified Bentall operation.", + "The aortic mechanical valve prosthesis was sutured into the graft at 1 cm from the end of the graft.", + "The composite graft was directly sutured to the left ventricular outflow tract.", + "The composite graft was fixed by outside the aortic wall with a belt-like Teflon felt.", + "The coronary buttons were anastomosed to the composite valve graft end-to-side.", + "The distal end of the conduit was anastomosed to the distal ascending aorta.", + "The CPB time was 117 min.", + "The aortic cross-clamp time was 60 min.", + "During the procedure, no difficult bleeding was encountered.", + "TEE suggested the aortic valve mechanical valve worked well.", + "Postoperative pathology indicated the inner layer of the arterial wall was uneven.", + "Postoperative pathology indicated partial fibrous hyperplasia.", + "Postoperative pathology indicated focal mucus degeneration.", + "Postoperative pathology indicated a few lymphocytes infiltration.", + "Immunohistochemical staining showed smooth muscle cells were positive.", + "Immunohistochemical staining showed CD3+ lymphocyte infiltration.", + "Web dyeing showed elastic fibers were positive.", + "Web dyeing suggested aseptic inflammatory changes in the aorta." + ], + "summary": "We report a case of BD combined with severe aortic valve regurgitation and two giant pseudoaneurysms of the aortic sinus. The patient underwent modified Bentall procedure (MBP) and use oral immunosuppressive as well as corticosteroid strictly, after 8 months follow-up, the patient recovered well.", + "summary_subclaims": [ + "The patient had Behcet's disease combined with severe aortic valve regurgitation.", + "The patient had two giant pseudoaneurysms of the aortic sinus.", + "The patient underwent modified Bentall procedure.", + "The patient used oral immunosuppressive therapy.", + "The patient used corticosteroid therapy.", + "After 8 months follow-up, the patient recovered well." + ] + }, + { + "id": "multiclinsum_test_2198_en.txt", + "fulltext": "The patient was a 48-year-old woman who had occasionally felt pain and swelling in her left forearm since childhood, but she had not visited a clinic because the pain resolved naturally. She had no medication history or surgical history, and no relevant family history. She had felt increasing pain and numbness in her left finger for about 1 month, and she was referred to our hospital after the pain increased further.\nHer forearm were broadly distended and the circumference of the left wrist was 1.2 cm longer than that of the right wrist. Grip strength was reduced by 11.4 kg on the left. Pain in the dorsiflexion of the wrist joint was noted, and the patient complained of numbness in the fingers. Electromyography showed a decreased amplitude of motor nerve conduction of the median nerve compared to the healthy side, but there was no delay in latency. Sensory nerve conduction velocity was undetectable on the affected side in the median nerve. The visual analogue scale for pain was 30/100.\nImaging findings showed no abnormalities on plain X-rays. MRI revealed hyperintensity on T2-weighted imaging and suggested that the vein had expanded from the proximal forearm to the palm . The size of the lesion was 16 × 2.2 × 3.3 cm. The median nerve was compressed by the vascular malformation invading the carpal tunnel.\nPregabalin was given for pain, but there was no improvement. Resection of the vascular malformation was considered to be invasive and to have a risk of incomplete resection. Therefore, carpal tunnel release was performed as an alternative treatment. A skin incision was made from the distal forearm to the palm, and the flexor retinaculum was opened. The veins were present on the ulnar side of the median nerve and were not touched during the procedure to avoid damage. Postoperatively, pain gradually diminished. One year after the operation, numbness of the finger disappeared and the patient was able to return to work. She has had no recurrence of symptoms due to the vascular malformation to date.", + "fulltext_subclaims": [ + "The patient was a 48-year-old woman.", + "She had occasionally felt pain and swelling in her left forearm since childhood.", + "She had not visited a clinic because the pain resolved naturally.", + "She had no medication history.", + "She had no surgical history.", + "She had no relevant family history.", + "She had felt increasing pain and numbness in her left finger for about 1 month.", + "She was referred to our hospital after the pain increased further.", + "Her forearm were broadly distended.", + "The circumference of the left wrist was 1.2 cm longer than that of the right wrist.", + "Grip strength was reduced by 11.4 kg on the left.", + "Pain in the dorsiflexion of the wrist joint was noted.", + "The patient complained of numbness in the fingers.", + "Electromyography showed a decreased amplitude of motor nerve conduction of the median nerve compared to the healthy side.", + "There was no delay in latency.", + "Sensory nerve conduction velocity was undetectable on the affected side in the median nerve.", + "The visual analogue scale for pain was 30/100.", + "Imaging findings showed no abnormalities on plain X-rays.", + "MRI revealed hyperintensity on T2-weighted imaging.", + "MRI suggested that the vein had expanded from the proximal forearm to the palm.", + "The size of the lesion was 16 × 2.2 × 3.3 cm.", + "The median nerve was compressed by the vascular malformation invading the carpal tunnel.", + "Pregabalin was given for pain.", + "There was no improvement.", + "Resection of the vascular malformation was considered to be invasive.", + "Resection of the vascular malformation was considered to have a risk of incomplete resection.", + "Carpal tunnel release was performed as an alternative treatment.", + "A skin incision was made from the distal forearm to the palm.", + "The flexor retinaculum was opened.", + "The veins were present on the ulnar side of the median nerve.", + "The veins were not touched during the procedure to avoid damage.", + "Postoperatively, pain gradually diminished.", + "One year after the operation, numbness of the finger disappeared.", + "The patient was able to return to work.", + "She has had no recurrence of symptoms due to the vascular malformation to date." + ], + "summary": "A 48-year-old woman complained of pain and paresthesia of the fingers, and was diagnosed with a large vascular malformation expanding from the proximal forearm to the palm on MRI. Because of the size of the lesion and involvement of soft tissue, resection had a risk of major hemorrhage and incomplete removal. Thus, carpal tunnel release was performed as a less invasive procedure, and was effective for reducing pain while avoiding the risks associated with resection.", + "summary_subclaims": [ + "The patient is a 48-year-old woman.", + "The patient complained of pain and paresthesia of the fingers.", + "The patient was diagnosed with a large vascular malformation expanding from the proximal forearm to the palm on MRI.", + "The lesion was large and involved soft tissue.", + "Resection had a risk of major hemorrhage.", + "Resection had a risk of incomplete removal.", + "Carpal tunnel release was performed as a less invasive procedure.", + "Carpal tunnel release was effective for reducing pain.", + "Carpal tunnel release avoided the risks associated with resection." + ] + }, + { + "id": "multiclinsum_test_3213_en.txt", + "fulltext": "66-year-old woman referred to the endocrinology department in 2001 for polynodular goiter and osteopenia, with increased sweating in the last year and mild, nonspecific polyarthralgia. She presented a subtle acromegaloid face (enlarged nose, thick lips and prominent superciliary arches) on physical examination. She reported that she had been wearing rings with a larger diameter in the last few years, but did not have an increase in the number of shoes. The biochemical profile showed a calcium level of 9.1 mg/dL (normal value: 8.5-10.5), phosphate level of 4.8 ng/dL (normal value: 2.5-4.5), 236 mg/24h calcium excretion (normal value: < 250) and 95% renal tubular reabsorption of phosphate (normal value: 85-94). Based on the clinical presentation, hyperphosphatemia with renal tubular reabsorption of phosphate at the upper limit of normal was suspected to be acromegaly. A measurement of plasma IGF-1 was requested and found within the normal range. PTOG/GH did not show suppression of the same: basal GH: 4.4 ng/mL, 30 minutes: 3.6, 60 minutes: 5, 90 minutes: 7.1 and 120 minutes: 5.5 (normal value: < 1 at all times of the test); confirming a hypersecretion of GH. The blood glucose levels were normal throughout the test: 97 and 139 mg/dL (basal and 120 minutes, respectively). The MRI of the hypophysis was normal, so the possible source of ectopic secretion of GH was sought. The MRI of the thorax and abdomen did not show a GH-producing tumour. Based on these results and with a patient who was oligosymptomatic for acromegaly, clinical and biochemical monitoring of the same was decided. In her clinical evolution there were no changes: she persists with hyperphosphatemia between 4.6 and 5.5 ng/dL, IGF-1 levels were slightly elevated to 2.3 (normal value: 2) and with annual PTOG/GH curves that were pathological (without suppression of GH). The oscillations in the serum phosphate and IGF-1 levels in the monitoring were modified in parallel. Annual MRI of the hypophysis was performed until 3 years of monitoring when a picture compatible with a 4 mm pituitary microadenoma was found, and an endoscopic transsphenoidal resection of the same was performed with good surgical resolution and without complications. The histopathological report reported somatotrophic adenoma of densely granulated cells, with immunohistochemical positivity for GH and with Ki67 labelling of 1.5%. Remission of acromegaly was achieved, maintaining IGF-1 levels within the normal range and PTOG/GH curve with suppression of GH. Clinical improvement was observed, normalisation of phosphatemia in parallel to normalisation of IGF-1 dosages. The patient remains in control and clinical monitoring in the institution for 18 years without recurrence of acromegaly. Informed consent of the patient and approval of the institution's ethics committee for the publication of the case was obtained.\n", + "fulltext_subclaims": [ + "The patient is a 66-year-old woman.", + "She was referred to the endocrinology department in 2001.", + "She had polynodular goiter.", + "She had osteopenia.", + "She had increased sweating in the last year.", + "She had mild, nonspecific polyarthralgia.", + "She had a subtle acromegaloid face.", + "She reported wearing rings with a larger diameter in the last few years.", + "The biochemical profile showed a calcium level of 9.1 mg/dL.", + "The phosphate level was 4.8 ng/dL.", + "The 24-hour calcium excretion was 236 mg.", + "The renal tubular reabsorption of phosphate was 95%.", + "Hyperphosphatemia with renal tubular reabsorption of phosphate at the upper limit of normal was suspected to be acromegaly.", + "A measurement of plasma IGF-1 was requested.", + "The plasma IGF-1 was found within the normal range.", + "The PTOG/GH did not show suppression of GH.", + "The basal GH was 4.4 ng/mL.", + "The 30-minute GH was 3.6 ng/mL.", + "The 60-minute GH was 5 ng/mL.", + "The 90-minute GH was 7.1 ng/mL.", + "The 120-minute GH was 5.5 ng/mL.", + "The blood glucose levels were normal throughout the test.", + "The MRI of the hypophysis was normal.", + "The MRI of the thorax and abdomen did not show a GH-producing tumour.", + "The patient was oligosymptomatic for acromegaly.", + "Clinical and biochemical monitoring of acromegaly was decided.", + "The patient persisted with hyperphosphatemia between 4.6 and 5.5 ng/dL.", + "The IGF-1 levels were slightly elevated to 2.3.", + "The annual PTOG/GH curves were pathological.", + "The oscillations in serum phosphate and IGF-1 levels were modified in parallel.", + "Annual MRI of the hypophysis was performed.", + "A 4 mm pituitary microadenoma was found after 3 years of monitoring.", + "An endoscopic transsphenoidal resection was performed.", + "The histopathological report reported a somatotrophic adenoma of densely granulated cells.", + "The Ki67 labelling was 1.5%.", + "Remission of acromegaly was achieved.", + "The patient remains in control and clinical monitoring for 18 years.", + "There was no recurrence of acromegaly.", + "Informed consent of the patient was obtained.", + "Approval of the institution's ethics committee was obtained." + ], + "summary": "We present the clinical case of a 66-year-old woman with persistent hyperphosphatemia 4.8 ng/dl (VN: 2.5-4.5) with high tubular reabsorption of phosphorus (RTP) 95% (VN: 85-94) with subtle features of acromegaly. Diagnosis of acromegaly was made with IGF1 dosages and oral glucose tolerance test with GH dosage (PTOG/GH). In search of the origin of the hypersecretion of GH, a resonance of the pituitary gland was requested, with the microadenoma of the pituitary gland being detected only in the third year of follow-up. Remission of the disease (IGF-1 in normal range) and normalization of phosphatemia after endoscopic transsphenoidal surgery were achieved. The patient continues the follow-up for 18 years without evidence of recurrence.\n", + "summary_subclaims": [ + "The patient is a 66-year-old woman.", + "The patient had persistent hyperphosphatemia of 4.8 ng/dl.", + "The normal range for phosphatemia is 2.5-4.5 ng/dl.", + "The patient had high tubular reabsorption of phosphorus of 95%.", + "The normal range for tubular reabsorption of phosphorus is 85-94%.", + "The patient had subtle features of acromegaly.", + "The diagnosis of acromegaly was made with IGF1 dosages.", + "The diagnosis of acromegaly was made with an oral glucose tolerance test with GH dosage (PTOG/GH).", + "A resonance of the pituitary gland was requested.", + "A microadenoma of the pituitary gland was detected in the third year of follow-up.", + "Remission of the disease was achieved after endoscopic transsphenoidal surgery.", + "Phosphatemia normalized after endoscopic transsphenoidal surgery.", + "The patient continues follow-up for 18 years.", + "There is no evidence of recurrence." + ] + }, + { + "id": "multiclinsum_test_501_en.txt", + "fulltext": "A 4-year-old Japanese boy presented with bilateral upper eyelid swelling and discomfort. The swelling was painless, but he complained of itchy eyelids. Ophthalmic examination revealed bilateral upper eyelid edema . No lymphadenopathy of the head or neck was observed. The patient had no medical history of atopic dermatitis, but local reactions to insect bites and vaccinations were excessive. There was no family history of autoimmune renal disease.\nUrinalysis results were normal. Blood analysis showed a white blood cell count of 8,200 /mL with a differential neutrophil count of 13%, a lymphocyte count of 55.5%, and a markedly increased eosinophil count of 28.5%. A peripheral smear revealed no abnormalities. The CD4/CD8 ratio was normal (1.46). Most laboratory blood examinations included electrolytes, serum creatinine, and blood urea nitrogen quantitation. The patient had an elevated aspartate aminotransferase level (34 IU/L; normal range, 14–20 IU/L), but alanine aminotransferase activity was within the normal range (16 IU/L; normal range, 10–40 IU/L). Lactate dehydrogenase and creatinine kinase activities were normal. The patient’s C-reactive protein level was 0.045 mg/dL, and he had an erythrocyte sedimentation rate of 9 mm/h. Immunoglobulin levels of IgG, IgA, IgD, IgM, and IgG4 were normal (IgG, 1,173 mg/dL; IgA, 162 mg/dL; IgD, 9.9 mg/dL; IgM 206 mg/dL; and IgG4 9.7 mg/dL). The patient had a highly elevated serum IgE level (14,351 IU/mL; reference range: 0–295 IU/mL). Serologic analyses for antinuclear antibody and MPO-ANCA were negative and serum complement components C3, C4, and total complement activity were normal. Chest radiography results were also normal, though magnetic resonance imaging (MRI) showed bilateral lacrimal gland enlargement without the appearance of mass lesions in the orbit and adjacent bony erosion .\nMikulicz disease was initially suspected, despite the IgG4 level being normal. Based on this presumptive diagnosis, pranlukast hydrate was administered for 2 years. However, follow-up treatment was suspended for 4 years as the symptoms did not improve. An excisional biopsy via anterior orbitotomy was performed at the age of 10 years, which revealed eosinophilic hyperplastic lymphogranuloma involving the lacrimal gland . A mixture of CD3-positive and CD5-positive T-cells was found within the interfollicular regions, and CD20-positive B-cells were observed within the follicles. A relatively smaller number of IgG-positive and IgG4-positive plasma cells were also observed. There was no evidence of either vasculitis or prominent vascular endothelial cell proliferation.\nBased on these findings, IgG4-related diseases, including Mikulicz disease, were excluded. Oral prednisolone was initiated at 1 mg/kg/day based on a diagnosis of lymphoproliferative disorder. The patient’s symptoms, including the eyelid edema, discomfort, and eosinophilia, were dramatically improved at the 1-month follow-up. However, symptoms recurred as prednisolone was tapered. A combinatorial therapy of prednisolone with mizoribine was subsequently initiated to mitigate the side effects of steroids. However, swelling of the bilateral eyelids worsened, and an itchy subcutaneous mass developed on the left arm. MRI examination revealed serpiginous subcutaneous lesions in the medial aspect of the left distal arm . The bilateral eyelid masses were resected when the patient was 14 years old due to their frequent recurrence, the side effects associated with steroid administration at the time of recurrence, and the negative impact the masses had on the patient’s physical appearance, and narrow field of view. Postoperative pathological examination of the excited masses showed hyperplastic lymphoid follicles embedded in fibroconnective tissue and multinuclear Whartin-Finkeldey cells, indicative of KD . Immunohistochemical analysis of the cells revealed negative staining for IgG and IgG4. The serum IL-4 level was elevated (500 pg/mL; reference range: < 6.0 pg/mL), but IL-5, IL-6, and interferon γ levels were normal. Serum sIL-2R levels were with in the reference range throughout the clinical course. The diagnosis of KD was confirmed based on the histological findings, markedly high serum IgE levels, and peripheral blood eosinophilia. Treatment with oral CsA at an initial dose of 2.5 mg/kg/day was started, which maintained at a trough level of approximately 50 ng/ml. The eosinophilia and serum IgE levels gradually decreased after initiation of CsA, but the IL-4 levels remained high. The CsA therapy was adjusted to 4mg/kg/day and the clinical symptoms were stable, without bilateral upper eyelid swelling or recurrence of the subcutaneous mass on the left arm .", + "fulltext_subclaims": [ + "A 4-year-old Japanese boy presented with bilateral upper eyelid swelling and discomfort.", + "The swelling was painless.", + "He complained of itchy eyelids.", + "Ophthalmic examination revealed bilateral upper eyelid edema.", + "No lymphadenopathy of the head or neck was observed.", + "The patient had no medical history of atopic dermatitis.", + "Local reactions to insect bites and vaccinations were excessive.", + "There was no family history of autoimmune renal disease.", + "Urinalysis results were normal.", + "Blood analysis showed a white blood cell count of 8,200 /mL.", + "The differential neutrophil count was 13%.", + "The lymphocyte count was 55.5%.", + "The eosinophil count was 28.5%.", + "A peripheral smear revealed no abnormalities.", + "The CD4/CD8 ratio was normal (1.46).", + "Most laboratory blood examinations included electrolytes, serum creatinine, and blood urea nitrogen quantitation.", + "The patient had an elevated aspartate aminotransferase level (34 IU/L; normal range, 14–20 IU/L).", + "The alanine aminotransferase activity was within the normal range (16 IU/L; normal range, 10–40 IU/L).", + "Lactate dehydrogenase and creatinine kinase activities were normal.", + "The patient’s C-reactive protein level was 0.045 mg/dL.", + "The erythrocyte sedimentation rate was 9 mm/h.", + "Immunoglobulin levels of IgG, IgA, IgD, IgM, and IgG4 were normal.", + "The patient had a highly elevated serum IgE level (14,351 IU/mL; reference range: 0–295 IU/mL).", + "Serologic analyses for antinuclear antibody and MPO-ANCA were negative.", + "Serum complement components C3, C4, and total complement activity were normal.", + "Chest radiography results were also normal.", + "Magnetic resonance imaging showed bilateral lacrimal gland enlargement.", + "Mikulicz disease was initially suspected.", + "Pranlukast hydrate was administered for 2 years.", + "Follow-up treatment was suspended for 4 years as the symptoms did not improve.", + "An excisional biopsy via anterior orbitotomy was performed at the age of 10 years.", + "The biopsy revealed eosinophilic hyperplastic lymphogranuloma involving the lacrimal gland.", + "A mixture of CD3-positive and CD5-positive T-cells was found within the interfollicular regions.", + "CD20-positive B-cells were observed within the follicles.", + "A relatively smaller number of IgG-positive and IgG4-positive plasma cells were also observed.", + "There was no evidence of either vasculitis or prominent vascular endothelial cell proliferation.", + "IgG4-related diseases, including Mikulicz disease, were excluded.", + "Oral prednisolone was initiated at 1 mg/kg/day based on a diagnosis of lymphoproliferative disorder.", + "The patient’s symptoms, including the eyelid edema, discomfort, and eosinophilia, were dramatically improved at the 1-month follow-up.", + "Symptoms recurred as prednisolone was tapered.", + "A combinatorial therapy of prednisolone with mizoribine was subsequently initiated.", + "Swelling of the bilateral eyelids worsened.", + "An itchy subcutaneous mass developed on the left arm.", + "MRI examination revealed serpiginous subcutaneous lesions in the medial aspect of the left distal arm.", + "The bilateral eyelid masses were resected when the patient was 14 years old.", + "Postoperative pathological examination showed hyperplastic lymphoid follicles embedded in fibroconnective tissue.", + "Multinuclear Whartin-Finkeldey cells were observed.", + "The diagnosis of KD was confirmed based on the histological findings, markedly high serum IgE levels, and peripheral blood eosinophilia.", + "Treatment with oral CsA at an initial dose of 2.5 mg/kg/day was started.", + "The CsA therapy was adjusted to 4 mg/kg/day.", + "The clinical symptoms were stable, without bilateral upper eyelid swelling or recurrence of the subcutaneous mass on the left arm." + ], + "summary": "We report a case of a 4-year-old Japanese boy presenting with bilateral upper eyelid swelling with nodular subcutaneous lesions and peripheral eosinophilia. Based on clinical, histopathological, and laboratory findings, the patient was diagnosed with KD. An itchy subcutaneous mass on the left arm developed at the age of 14 years. Treatment with steroids was effective. However, as the steroids were tapered after the patient developed side effects, the masses relapsed within a few months. Treatment with cyclosporine A was then initiated, which led to an improvement of clinical features and serial levels of cytokines.", + "summary_subclaims": [ + "The patient was a 4-year-old Japanese boy.", + "The patient had bilateral upper eyelid swelling.", + "The patient had nodular subcutaneous lesions.", + "The patient had peripheral eosinophilia.", + "The patient was diagnosed with KD.", + "An itchy subcutaneous mass on the left arm developed at the age of 14 years.", + "Treatment with steroids was effective.", + "The steroids were tapered after the patient developed side effects.", + "The masses relapsed within a few months.", + "Treatment with cyclosporine A was then initiated.", + "Cyclosporine A led to an improvement of clinical features.", + "Serial levels of cytokines were measured." + ] + }, + { + "id": "multiclinsum_test_271_en.txt", + "fulltext": "A 48-year-old Chinese woman with a history of a right parasagittal meningioma with surgery and gamma knife excision done, was first put on valproate but then stepped up to topiramate 26 months later for uncontrolled seizures. The initial dose was topiramate 25 mg twice a day, which was eventually stepped up to 100 mg twice a day for adequate seizure control. She was referred to our ophthalmology clinic for dry eyes before the use of topiramate, with an examination showing a baseline visual acuity of 1.2 in both eyes with unremarkable anterior segment and fundoscopy examination. There was no family history of retinal diseases.\nShe complained of blurring of vision in both eyes after using topiramate for 9 months. She was not on other medications when her visual symptoms developed. On examination, her visual acuity was 0.7 in both eyes. Her pupils were equal with no relative afferent papillary defect. The intraocular pressure, Ishihara test, and anterior segment examination were within normal limits. A fundus examination revealed there was bilateral diffuse pigmentary retinopathy . Automated perimetry showed bilateral peripheral constrictions while microperimetry showed normal macula sensitivity . Autofluorescence fundus pictures showed loss of autofluorescence at the periphery, which is compatible with areas of pigmentary retinopathy . A fundus fluorescein angiogram also showed blocked fluorescence in the areas of pigmentation . Optical coherence tomography was unremarkable. A full field electroretinogram (ERG) according to International Society for Clinical Electrophysiology of Vision (ISCEV) standard was performed at 16 months after onset of symptoms (25 months since topiramate was first given). Both photopic and scotopic responses were found to be within normal limits. Administration of topiramate was immediately ceased due to suspected correlation with her eye signs and symptoms. She was switched to levetiracetam monotherapy. There was no more seizure recurrence after this treatment change.\nAll investigations were repeated 1 year after discontinuation of topiramate. Bilateral diffuse pigmentary retinopathy was still present, with visual field test showing similar peripheral constriction, although her visual acuity improved back to 1.0 in both eyes and she reported subjective improvement in vision.", + "fulltext_subclaims": [ + "The patient is a 48-year-old Chinese woman.", + "She has a history of a right parasagittal meningioma with surgery and gamma knife excision.", + "She was first put on valproate.", + "She was stepped up to topiramate 26 months later for uncontrolled seizures.", + "The initial dose of topiramate was 25 mg twice a day.", + "The dose was eventually stepped up to 100 mg twice a day.", + "She was referred to the ophthalmology clinic for dry eyes before the use of topiramate.", + "The baseline visual acuity was 1.2 in both eyes.", + "The anterior segment and fundoscopy examination were unremarkable.", + "There was no family history of retinal diseases.", + "She complained of blurring of vision in both eyes after using topiramate for 9 months.", + "She was not on other medications when her visual symptoms developed.", + "On examination, her visual acuity was 0.7 in both eyes.", + "The pupils were equal with no relative afferent papillary defect.", + "The intraocular pressure, Ishihara test, and anterior segment examination were within normal limits.", + "A fundus examination revealed bilateral diffuse pigmentary retinopathy.", + "Automated perimetry showed bilateral peripheral constrictions.", + "Microperimetry showed normal macula sensitivity.", + "Autofluorescence fundus pictures showed loss of autofluorescence at the periphery.", + "A fundus fluorescein angiogram showed blocked fluorescence in the areas of pigmentation.", + "Optical coherence tomography was unremarkable.", + "A full field electroretinogram was performed 16 months after onset of symptoms.", + "Both photopic and scotopic responses were within normal limits.", + "Administration of topiramate was immediately ceased due to suspected correlation with her eye signs and symptoms.", + "She was switched to levetiracetam monotherapy.", + "There was no more seizure recurrence after this treatment change.", + "All investigations were repeated 1 year after discontinuation of topiramate.", + "Bilateral diffuse pigmentary retinopathy was still present.", + "The visual field test showed similar peripheral constriction.", + "Her visual acuity improved back to 1.0 in both eyes.", + "She reported subjective improvement in vision." + ], + "summary": "A 48-year-old Chinese woman developed blurred vision after 9 months of topiramate use. Her visual acuity dropped from 1.2 to 0.7 in both eyes, with bilateral diffuse pigmentary retinopathy and a constricted visual field. Despite an improvement in visual acuity after cessation of the drug, the other clinical findings remained. The temporal relationship between the initiation of topiramate and the visual disturbance suggests that topiramate could be the cause of such signs and symptoms.", + "summary_subclaims": [ + "The patient is a 48-year-old Chinese woman.", + "She developed blurred vision after 9 months of topiramate use.", + "Her visual acuity dropped from 1.2 to 0.7 in both eyes.", + "Bilateral diffuse pigmentary retinopathy was observed.", + "A constricted visual field was observed.", + "Visual acuity improved after cessation of the drug.", + "The other clinical findings remained after cessation of the drug.", + "The temporal relationship between the initiation of topiramate and the visual disturbance suggests that topiramate could be the cause of such signs and symptoms." + ] + }, + { + "id": "multiclinsum_test_2537_en.txt", + "fulltext": "A 53-year-old woman presented with bilateral visual loss. She had a prior history of “IIH” by modified Dandy criteria 19 years prior but aggressive surgical treatment with lumboperitoneal shunt placement and two revisions failed to improve the vision. She had a pituitary adenoma that was resected but the vision did not improve and she presented with 3 weeks later with new-onset headache and visual loss. Her BMI was 35.44 kg/m2. Past medical history included depression, hepatitis C, hyperlipidemia, and uterine cancer post-hysterectomy. The patient was taking trazodone for anxiety and buprenorphine for chronic pain. She had allergies to penicillin, tolterodine, ondansetron, metoclopramide, and prochlorperazine. She never smoked and had no history of alcohol or drug use. The family history was non-contributory.\nAt presentation she reported new headaches, transient visual obscurations, and a history of “papilledema” and “IIH” in 2003, at the age of 35. In 2003, cranial magnetic resonance imaging (MRI) was normal and lumbar puncture (LP) revealed normal CSF contents but an elevated opening pressure, which was compatible with the modified Dandy criteria for IIH. The patient had progressive visual loss that required LP shunt and had a subsequent shunt revision.\nFrom 2015 to 2018, she began experiencing painless peripheral vision loss, which she and her physicians attributed to “old damage from the pseudotumor cerebri”.\nThe patient presented again in 2018 with progressive peripheral vision loss in both eyes. A repeat cranial MRI showed a prior stable mild Chiari I malformation but a new suprasellar pituitary adenoma . A diagnosis of compression optic neuropathy was made. Visual acuity was hand motion in the right eye (OD) and 20/60 in the left eye (OS). Automated perimetry (Humphrey visual field (HVF) 24 − 2) revealed a temporal hemianopic impairment with a superimposed inferior altitudinal field loss OS and diffuse depression OD. Repeat LP results revealed normal CSF and opening pressure. The patient had a Grade 1 pituitary adenoma removed completely via a transnasal technique, but her vision did not improve, likely due to the prior optic atrophy that was present for years prior to resection.\nIn February 2020 the patient presented to the neuro-ophthalmology clinic at Houston Methodist Hospital with one-month worsening headaches and vision loss for which she was admitted. On neuro-ophthalmic examination, the visual acuity was no light perception OD and counting fingers OS. The right pupil was amaurotic. Optical coherence tomography (OCT) of the retinal nerve fiber layer and the macular ganglion cell layer showed diffuse loss OU. New subretinal and intraretinal edema was seen on OCT and ophthalmoscopy showed diffuse optic atrophy OU.\nRepeat cranial MRI showed gross total resection of the pituitary adenoma with no recurrent or residual disease. LP showed normal opening pressure and CSF content. Repeat orbital MRI with contrast however showed symmetric thin peripheral optic nerve sheath enhancement of the intra-orbital optic nerves OU . Serum MOG-Ab testing was positive at a 1:100 titer. She was treated with intravenous steroids followed by plasma exchange and rituximab. There was an improvement of subretinal fluid collection following the plasma exchange, and she continued rituximab every 6 months. In September of 2020 her VA was NLP OD and 20/400 OS but the incomplete improvement was attributed to prior optic atrophy. In August of 2021 OCT was done and her VA was stable at NLP OD and 20/400 OS. On May 3, 2022, she presented with 3 weeks of worsening vision and headaches, her VA was NLP OD and CF OS, with a right RAPD, on OCT global was 75 OD and 67 OS after being 99 OD and 84 OS and showed bilateral optic atrophy despite treatment for MOGAD likely due to the delayed treatment of MOGAD.", + "fulltext_subclaims": [ + "The patient is a 53-year-old woman.", + "She had a prior history of \"IIH\" by modified Dandy criteria 19 years prior.", + "She had aggressive surgical treatment with lumboperitoneal shunt placement and two revisions.", + "The surgical treatment failed to improve the vision.", + "She had a pituitary adenoma that was resected.", + "The vision did not improve after the pituitary adenoma resection.", + "She presented with new-onset headache and visual loss.", + "Her BMI was 35.44 kg/m2.", + "Past medical history included depression, hepatitis C, hyperlipidemia, and uterine cancer post-hysterectomy.", + "She was taking trazodone for anxiety and buprenorphine for chronic pain.", + "She had allergies to penicillin, tolterodine, ondansetron, metoclopramide, and prochlorperazine.", + "She never smoked.", + "The family history was non-contributory.", + "At presentation she reported new headaches and transient visual obscurations.", + "She had a history of \"papilledema\" and \"IIH\" in 2003.", + "In 2003, cranial magnetic resonance imaging (MRI) was normal.", + "In 2003, lumbar puncture (LP) revealed normal CSF contents.", + "In 2003, LP revealed an elevated opening pressure.", + "The 2003 findings were compatible with the modified Dandy criteria for IIH.", + "The patient had progressive visual loss that required LP shunt.", + "She had a subsequent shunt revision.", + "From 2015 to 2018, she began experiencing painless peripheral vision loss.", + "The painless peripheral vision loss was attributed to \"old damage from the pseudotumor cerebri\".", + "In 2018, she presented with progressive peripheral vision loss in both eyes.", + "A repeat cranial MRI showed a prior stable mild Chiari I malformation.", + "A repeat cranial MRI showed a new suprasellar pituitary adenoma.", + "A diagnosis of compression optic neuropathy was made.", + "Visual acuity was hand motion in the right eye (OD) and 20/60 in the left eye (OS).", + "Automated perimetry (Humphrey visual field (HVF) 24 − 2) revealed a temporal hemianopic impairment with a superimposed inferior altitudinal field loss OS.", + "Automated perimetry revealed diffuse depression OD.", + "Repeat LP results revealed normal CSF.", + "Repeat LP results revealed normal opening pressure.", + "The patient had a Grade 1 pituitary adenoma removed completely via a transnasal technique.", + "Her vision did not improve after the pituitary adenoma resection.", + "The lack of improvement was likely due to prior optic atrophy.", + "In February 2020, the patient presented to the neuro-ophthalmology clinic at Houston Methodist Hospital.", + "She had one-month worsening headaches and vision loss.", + "On neuro-ophthalmic examination, the visual acuity was no light perception OD and counting fingers OS.", + "The right pupil was amaurotic.", + "Optical coherence tomography (OCT) of the retinal nerve fiber layer and the macular ganglion cell layer showed diffuse loss OU.", + "New subretinal and intraretinal edema was seen on OCT.", + "Ophthalmoscopy showed diffuse optic atrophy OU.", + "Repeat cranial MRI showed gross total resection of the pituitary adenoma.", + "Repeat cranial MRI showed no recurrent or residual disease.", + "LP showed normal opening pressure.", + "LP showed normal CSF content.", + "Repeat orbital MRI with contrast showed symmetric thin peripheral optic nerve sheath enhancement of the intra-orbital optic nerves OU.", + "Serum MOG-Ab testing was positive at a 1:100 titer.", + "She was treated with intravenous steroids.", + "She was treated with plasma exchange.", + "She was treated with rituximab.", + "There was an improvement of subretinal fluid collection following the plasma exchange.", + "She continued rituximab every 6 months.", + "In September of 2020, her VA was NLP OD and 20/400 OS.", + "The incomplete improvement was attributed to prior optic atrophy.", + "In August of 2021, OCT was done and her VA was stable at NLP OD and 20/400 OS.", + "On May 3, 2022, she presented with 3 weeks of worsening vision and headaches.", + "Her VA was NLP OD and CF OS.", + "She had a right RAPD.", + "On OCT, global was 75 OD and 67 OS.", + "The OCT values were after being 99 OD and 84 OS.", + "There was bilateral optic atrophy despite treatment for MOGAD.", + "The optic atrophy was likely due to the delayed treatment of MOGAD." + ], + "summary": "A 53-year-old woman with a history of presumed idiopathic intracranial hypertension (\"IIH\") presented with new headache and visual loss. She had a BMI of 35.44 kg/m2 and a past medical history significant for depression, hepatitis C, hyperlipidemia, and uterine cancer post-hysterectomy. She had undergone multiple lumboperitoneal shunts for presumed IIH and had a prior pituitary adenoma resection. Her visual acuity was no light perception OD and counting fingers OS. After neuro-ophthalmic consultation, a repeat cranial MRI showed symmetric thin peripheral optic nerve sheath enhancement of the intra-orbital optic nerves OU. Serum MOG antibody was positive at 1:100 and she was treated with intravenous steroids followed by plasma exchange and rituximab.", + "summary_subclaims": [ + "The patient is a 53-year-old woman.", + "She has a history of presumed idiopathic intracranial hypertension.", + "She presented with new headache and visual loss.", + "Her BMI was 35.44 kg/m2.", + "She has a past medical history significant for depression.", + "She has a past medical history significant for hepatitis C.", + "She has a past medical history significant for hyperlipidemia.", + "She has a past medical history significant for uterine cancer post-hysterectomy.", + "She had undergone multiple lumboperitoneal shunts for presumed IIH.", + "She had a prior pituitary adenoma resection.", + "Her visual acuity was no light perception OD.", + "Her visual acuity was counting fingers OS.", + "A repeat cranial MRI showed symmetric thin peripheral optic nerve sheath enhancement of the intra-orbital optic nerves OU.", + "Serum MOG antibody was positive at 1:100.", + "She was treated with intravenous steroids.", + "She was treated with plasma exchange.", + "She was treated with rituximab." + ] + }, + { + "id": "multiclinsum_test_2952_en.txt", + "fulltext": "A 28-year-old woman consulted the hospital for left chest paroxysmal pricking in 2014. Chest plain computed tomography (CT) scans revealed approximately 10 demarcated, round, homogeneous, unequally sized nodules without evidence of calcification, necrosis, or cavitation in the left lower lobe. Regular follow-up was suggested, and the same CT findings were obtained in 2016. In March 2019, she was admitted to our hospital for further evaluation because a plain chest CT scan showed larger, more numerous nodules. There were approximately 49 nodules, the largest of which was 2.8 cm in diameter . Interestingly, all nodules were in the left lower lobe. Contrast-enhanced arterial phase CT showed intense heterogeneous enhancement , and the delay phase showed homogenous nodules . CT-guided biopsy was performed to determine the nodule’s nature. Pathology indicated CCTL. No distal metastasis was found; therefore, left lower lobectomy and mediastinal lymph node dissection (stations 5, 7, 8, 9, 10, and 11) were performed. Postoperative pathological analysis confirmed the diagnosis of CCTL. Grossly, the tumor was solid, gray-white, with a soft texture and clear boundaries . The largest CCTL nodule measured 2.8 cm.\nHE staining showed that the tumor consisted of round, clear cells with distinct cell borders and a granular eosinophilic cytoplasm . Histology revealed cytoplasmic PAS-positive clear cells without atypia, mitosis, or necrosis . The immunohistochemical profile of the clear cells was positive for HMB45 , CD34 , and Vimentin. Tumor reactivity was negative for cytokeratin , SMA , S-100, CD10, PAX-8, desmin, and Myo-D1. No lymphatic metastasis was observed. The postoperative course was uneventful. No evidence of metastasis or recurrence was observed during the 6-month follow-up period after the surgery.", + "fulltext_subclaims": [ + "A 28-year-old woman consulted the hospital for left chest paroxysmal pricking in 2014.", + "Chest plain computed tomography (CT) scans revealed approximately 10 demarcated, round, homogeneous, unequally sized nodules.", + "The nodules showed no evidence of calcification, necrosis, or cavitation.", + "The nodules were located in the left lower lobe.", + "Regular follow-up was suggested.", + "The same CT findings were obtained in 2016.", + "In March 2019, she was admitted to our hospital for further evaluation.", + "A plain chest CT scan showed larger, more numerous nodules.", + "There were approximately 49 nodules.", + "The largest nodule was 2.8 cm in diameter.", + "All nodules were in the left lower lobe.", + "Contrast-enhanced arterial phase CT showed intense heterogeneous enhancement.", + "The delay phase showed homogenous nodules.", + "CT-guided biopsy was performed to determine the nodule’s nature.", + "Pathology indicated CCTL.", + "No distal metastasis was found.", + "Left lower lobectomy and mediastinal lymph node dissection were performed.", + "Postoperative pathological analysis confirmed the diagnosis of CCTL.", + "Grossly, the tumor was solid, gray-white, with a soft texture and clear boundaries.", + "The largest CCTL nodule measured 2.8 cm.", + "HE staining showed that the tumor consisted of round, clear cells with distinct cell borders and a granular eosinophilic cytoplasm.", + "Histology revealed cytoplasmic PAS-positive clear cells without atypia, mitosis, or necrosis.", + "The immunohistochemical profile of the clear cells was positive for HMB45.", + "The immunohistochemical profile was positive for CD34.", + "The immunohistochemical profile was positive for Vimentin.", + "Tumor reactivity was negative for cytokeratin.", + "Tumor reactivity was negative for SMA.", + "Tumor reactivity was negative for S-100.", + "Tumor reactivity was negative for CD10.", + "Tumor reactivity was negative for PAX-8.", + "Tumor reactivity was negative for desmin.", + "Tumor reactivity was negative for Myo-D1.", + "No lymphatic metastasis was observed.", + "The postoperative course was uneventful.", + "No evidence of metastasis or recurrence was observed during the 6-month follow-up period after the surgery." + ], + "summary": "We describe a case of a 28-year-old woman with multiple gradually replicating and enlarging nodules in the left lower lobe. The patient underwent fine-needle aspiration biopsy and was diagnosed with CCTL. A left lower lobectomy and mediastinal lymph node dissection were performed. The gradual changes in size (1.4 cm to 2.8 cm) and quantity (10 to 49) of the CCTLs in this case were the biggest differences from previously reported cases.", + "summary_subclaims": [ + "The patient was a 28-year-old woman.", + "The patient had multiple gradually replicating and enlarging nodules in the left lower lobe.", + "The patient underwent fine-needle aspiration biopsy.", + "The patient was diagnosed with CCTL.", + "A left lower lobectomy was performed.", + "A mediastinal lymph node dissection was performed.", + "The CCTLs increased in size from 1.4 cm to 2.8 cm.", + "The CCTLs increased in quantity from 10 to 49.", + "The gradual changes in size and quantity of the CCTLs were the biggest differences from previously reported cases." + ] + }, + { + "id": "multiclinsum_test_2437_en.txt", + "fulltext": "A 50-year-old hypertensive woman presented to the emergency department of our hospital presenting headache while shopping. There was no history of preceding falls or head injuries. She had not been administered steroids, anticoagulants, or antiplatelet agents. At presentation, the patient was fully awake and did not exhibit any focal neurological deficits. The blood pressure was 176/113 mmHg, and blood examination revealed normal findings. Cranial computed tomography (CT) revealed a subtly compressive, apparently ASDH in the left cerebral convexity. It was 15 mm in thickness without displacement of midline structures and showed a regression in 1 day with resolution of the headache . Three-dimensional CT angiography showed no vascular lesions in the intracranial dural sinuses or major cortical veins . Cerebral magnetic resonance imaging (MRI) performed on post hospitalization day (PHD) 6 revealed a non-enhancing, nodular lesion in the subdural hematoma, and adjacent to the left parietal cortex . The patient was conservatively managed based on a probable diagnosis of non-traumatic ASDH. However, the patient presented with disorientation and aphasia on PHD 14; CT showed a considerable enlargement of the subdural hematoma with better delineation of the nodular lesion on T2-weighted sequence . Catheter angiography performed on PHD 14 did not reveal any intracranial vascular lesions. The patient underwent removal of the microsurgical hematoma including the nodular lesion through a 5 × 5-cm parietal craniotomy. The subdural hematoma showed a bi-layered structure comprising a thick outer membrane and inner semisolid clots. The cerebral cortex underneath the hematoma was intact. The nodular lesion identified previously on MRI, possessed a fibrous capsule, included clots, and adhered to the outer membrane of the hematoma and arachnoids. These attachments were bluntly dissected without injuring the cortical vessels coursing underneath . Abnormal vasculature was not found between the lesion and surrounding tissues. The outer membrane of the hematoma and the semisolid subdural clots were partially removed. Microscopically, the resected outer membrane of the CSDH and the nodular lesion revealed areas of microvascular proliferation . The patient’s postoperative recovery period was uneventful. On postoperative day 35, CT showed a remarkable resolution of the residual hematoma .", + "fulltext_subclaims": [ + "The patient was a 50-year-old hypertensive woman.", + "She presented to the emergency department with headache while shopping.", + "There was no history of preceding falls or head injuries.", + "She had not been administered steroids, anticoagulants, or antiplatelet agents.", + "At presentation, the patient was fully awake.", + "The patient did not exhibit any focal neurological deficits.", + "The blood pressure was 176/113 mmHg.", + "Cranial CT revealed a subtly compressive, apparently ASDH in the left cerebral convexity.", + "The ASDH was 15 mm in thickness without displacement of midline structures.", + "The ASDH showed a regression in 1 day with resolution of the headache.", + "Three-dimensional CT angiography showed no vascular lesions in the intracranial dural sinuses or major cortical veins.", + "Cerebral MRI performed on post hospitalization day 6 revealed a non-enhancing, nodular lesion in the subdural hematoma.", + "The nodular lesion was adjacent to the left parietal cortex.", + "The patient was conservatively managed based on a probable diagnosis of non-traumatic ASDH.", + "The patient presented with disorientation and aphasia on post hospitalization day 14.", + "CT showed a considerable enlargement of the subdural hematoma.", + "The nodular lesion was better delineated on T2-weighted sequence.", + "Catheter angiography performed on post hospitalization day 14 did not reveal any intracranial vascular lesions.", + "The patient underwent removal of the microsurgical hematoma including the nodular lesion through a 5 × 5-cm parietal craniotomy.", + "The subdural hematoma showed a bi-layered structure comprising a thick outer membrane and inner semisolid clots.", + "The cerebral cortex underneath the hematoma was intact.", + "The nodular lesion identified previously on MRI possessed a fibrous capsule.", + "The nodular lesion included clots and adhered to the outer membrane of the hematoma and arachnoids.", + "The attachments were bluntly dissected without injuring the cortical vessels coursing underneath.", + "Abnormal vasculature was not found between the lesion and surrounding tissues.", + "The outer membrane of the hematoma and the semisolid subdural clots were partially removed.", + "Microscopically, the resected outer membrane of the CSDH and the nodular lesion revealed areas of microvascular proliferation.", + "The patient’s postoperative recovery period was uneventful.", + "On postoperative day 35, CT showed a remarkable resolution of the residual hematoma." + ], + "summary": "A 50-year-old hypertensive woman experienced headache without any previous head injury. At presentation, the patient showed no focal neurological deficits. Cranial computed tomography (CT) revealed a slightly compressive subdural hematoma that spontaneously regressed and no intracranial vascular lesions. Cerebral magnetic resonance imaging identified a non-enhancing nodular lesion in the subdural hematoma. After the patient presented disorientation and aphasia on post hospitalization day 14, CT showed a considerable enlargement of the subdural hematoma. Partial removal of the bi-layered hematoma was performed through a parietal craniotomy. Histological examination revealed microvascular proliferation in both the outer membrane and the nodular lesion. On postoperative day 35, CT demonstrated a remarkable resolution of the residual hematoma.", + "summary_subclaims": [ + "The patient is a 50-year-old hypertensive woman.", + "The patient experienced headache without any previous head injury.", + "At presentation, the patient showed no focal neurological deficits.", + "Cranial CT revealed a slightly compressive subdural hematoma.", + "Cranial CT showed no intracranial vascular lesions.", + "Cerebral MRI identified a non-enhancing nodular lesion in the subdural hematoma.", + "On post hospitalization day 14, the patient presented disorientation and aphasia.", + "CT on post hospitalization day 14 showed a considerable enlargement of the subdural hematoma.", + "Partial removal of the bi-layered hematoma was performed through a parietal craniotomy.", + "Histological examination revealed microvascular proliferation in both the outer membrane and the nodular lesion.", + "On postoperative day 35, CT demonstrated a remarkable resolution of the residual hematoma." + ] + }, + { + "id": "multiclinsum_test_2274_en.txt", + "fulltext": "A 20-year-old female presented with a complaints of amenorrhea, left flank pain and heaviness from 1 year. There was no associated weight loss, and patient was vitally stable. Flank pain was gradual in onset and progress and diffuse in nature. On physical examination patient was of normal height and weight but systemic examination a left renal mass was palpated that felt homogeneous in nature. At presentation Patient was vitally stable and laboratory investigations ordered were also with in normal standard reference ranges expect Hb level, that was slightly towards lower normal limit. On ultrasound study a left renal mass involving the major portion of left renal tissue with homogeneous density was observed. The ultrasound also revealed a tumor like image that was occupying the whole left kidney (upper, middle, and lower borders). On further investigations computerized tomography (CT) scan revealed size of 180 mm with no invasions to renal capsule, renal vessels, or ureters or homolateral adrenal gland as shown in a and b. Infiltrative borders of tumor mass suggested as an untypically renal cell carcinoma. Therefore, radical nephrectomy was done.\nDuring operation the renal capsule was found intact, and the renal artery was clamped, no complications were faced during operation and patient had quick and perfect recovery post operatively. Gross examination of the specimen revealed a tumor dimension of 180 × 150 × 110 mm involving the whole kidney middle upper and lower lobe as shown in . Ureters, renal vein, renal capsule, perinephric mass uninvolved by tumor. However renal sinus fat was completely replaced by tumor. Cut surface of the tumor shows multiple small cysts, filled with clear fluid.\nPatient was informed about the nature of the disease and patient was prepared for radical nephrectomy after getting anaesthesia fitness. Tumor mass was removed by radical nephrectomy that was performed through transperitoneal approach as shown in and the resected specimen was preserved for microscopic and histological analysis. Microscopic and histological sections showed multi-cystic structures with variably sized simple cysts lined by hobnailed epithelium with clear cells. Septa show ovarian type fibrous stroma with variable inflammation and immature nephrogenic elements. Final histopathological diagnosis was Mixed Epithelial and Stromal Tumor (MEST) and patient was placed on strict follow up, irrespective of that the malignant transformation and recurrence history is very rare of natural history of MEST.", + "fulltext_subclaims": [ + "The patient is a 20-year-old female.", + "The patient had complaints of amenorrhea, left flank pain, and heaviness for 1 year.", + "There was no associated weight loss.", + "The patient was vitally stable.", + "Flank pain was gradual in onset and progressive.", + "Flank pain was diffuse in nature.", + "On physical examination, a left renal mass was palpated.", + "The left renal mass felt homogeneous in nature.", + "Laboratory investigations were within normal standard reference ranges, except Hb level, which was slightly towards the lower normal limit.", + "An ultrasound study showed a left renal mass involving the major portion of left renal tissue with homogeneous density.", + "The ultrasound revealed a tumor-like image occupying the whole left kidney (upper, middle, and lower borders).", + "A CT scan showed the tumor size was 180 mm.", + "The CT scan showed no invasion to the renal capsule, renal vessels, or ureters.", + "The CT scan showed no invasion to the homolateral adrenal gland.", + "Infiltrative borders of the tumor mass suggested an atypical renal cell carcinoma.", + "Radical nephrectomy was done.", + "During operation, the renal capsule was found intact.", + "The renal artery was clamped.", + "No complications were faced during the operation.", + "The patient had a quick and perfect recovery postoperatively.", + "Gross examination of the specimen revealed a tumor dimension of 180 × 150 × 110 mm.", + "The tumor involved the whole kidney middle, upper, and lower lobe.", + "Ureters, renal vein, renal capsule, and perinephric mass were uninvolved by tumor.", + "Renal sinus fat was completely replaced by tumor.", + "The cut surface of the tumor showed multiple small cysts filled with clear fluid.", + "The tumor mass was removed by radical nephrectomy.", + "The radical nephrectomy was performed through a transperitoneal approach.", + "Microscopic and histological sections showed multi-cystic structures with variably sized simple cysts lined by hobnailed epithelium with clear cells.", + "Septa showed ovarian-type fibrous stroma with variable inflammation.", + "Septa showed immature nephrogenic elements.", + "The final histopathological diagnosis was Mixed Epithelial and Stromal Tumor (MEST).", + "The patient was placed on strict follow-up.", + "Malignant transformation and recurrence history is very rare in the natural history of MEST." + ], + "summary": "A 20 years old female presented to surgical outpatient department with complaint of amenorrhea and left flank pain as well as heaviness for 1 year. Patient was vitally stable and cooperative. On physical examination left flank mass was palpated and ultrasound and CT scan imaging was also showing left renal mass confined to upper, middle and lower portion of the kidney while renal capsule, adrenal gland and ureter were spared. On histological examination showed multi-cystic structures with variably sized simple cysts lined by hobnailed epithelium with clear cells. Septa show ovarian type fibrous stroma with variable inflammation and immature nephrogenic elements. A final diagnosis of MEST was made. Therefore, radical nephrectomy with trans-peritoneal approach was done.", + "summary_subclaims": [ + "The patient is a 20 years old female.", + "The patient presented with amenorrhea.", + "The patient reported left flank pain and heaviness for 1 year.", + "On physical examination, a left flank mass was palpated.", + "Ultrasound and CT scan imaging showed a left renal mass confined to the upper, middle, and lower portions of the kidney.", + "The renal capsule, adrenal gland, and ureter were spared.", + "Histological examination showed multi-cystic structures with variably sized simple cysts.", + "The cysts were lined by hobnailed epithelium with clear cells.", + "The septa showed ovarian type fibrous stroma.", + "The septa showed variable inflammation.", + "The septa showed immature nephrogenic elements.", + "A final diagnosis of MEST was made.", + "Radical nephrectomy with trans-peritoneal approach was done." + ] + }, + { + "id": "multiclinsum_test_995_en.txt", + "fulltext": "A 21-year-old man presented to the emergency room (ER) complaining of stomach and serious back pain 2 months after spinal surgical intervention. Two months before his visit, he fell from a 10 m tall building. He was confirmed as suffering fracture and dislocation from T11 to L2 by a computed tomography (CT) examination. The patient complained of severe back pain. There was no neural deficit. The patient underwent thoracolumbar pedicle screw implant surgery using ‘freehand technique’ under fluoroscopic guidance in a local hospital. Eight pedicle screws with contoured rods were placed spanning T11 to L2 after the correction of deformities. The patient tolerated the procedure well and developed no neurodeficits postoperatively. Radiological examination revealed a partial correction of the deformity.\nThe patient was presented with a recurrence of pain at the operated site 10 days postoperatively. The pain was a dull ache, non-radiating, and showed a progressive increase in intensity. This was accompanied by constitutional symptoms like poor appetite and a general feeling of being unwell. In view of the non-specific nature of the complaints, no further investigation was carried out and the patient was advised to attend regular follow-ups.\nIn our hospital, enhanced CT and X-rays were performed after thorough clinical evaluation. The CT scan revealed the malposition of a pedicle screw on both sides at the T11, T12, and L1 levels, which was a disaster. The left side T12 and L1 malpositioned screws had exited the lateral pedicle cortex and were clearly abutting the posteromedial aspect of the descending thoracic aorta , with the formation of associated pseudoaneurysms in the thoracic aorta. The right side of T11 and both sides of T12 screws also had exited the lateral pedicle cortex and were abutting the wall of the pseudoaneurysm. The left side screw in L2 perforated the lateral pedicle cortex but did not abut the aorta . A re-surgery with the interdisciplinary collaboration of orthopaedics and vascular surgery teams was recommended and was subsequently performed in another hospital. In the surgery, after the anesthesia and cardiopulmonary bypass, pseudoaneurysm and malpositioned screws were found under direct vision. An ascending aorta replacement with artificial tissue was performed (Vascutek Ltd., diameter 16 × 8 mm, usable length 45 cm). The extruded part of the pedicle screw was cut in situ so as to avoid any chance of re-injury. The patient endured the surgery well and had a good recovery in his 4-month follow-up examination.", + "fulltext_subclaims": [ + "A 21-year-old man presented to the emergency room (ER) complaining of stomach and serious back pain 2 months after spinal surgical intervention.", + "Two months before his visit, he fell from a 10 m tall building.", + "He was confirmed as suffering fracture and dislocation from T11 to L2 by a computed tomography (CT) examination.", + "The patient complained of severe back pain.", + "There was no neural deficit.", + "The patient underwent thoracolumbar pedicle screw implant surgery using ‘freehand technique’ under fluoroscopic guidance in a local hospital.", + "Eight pedicle screws with contoured rods were placed spanning T11 to L2 after the correction of deformities.", + "The patient tolerated the procedure well and developed no neurodeficits postoperatively.", + "Radiological examination revealed a partial correction of the deformity.", + "The patient was presented with a recurrence of pain at the operated site 10 days postoperatively.", + "The pain was a dull ache, non-radiating, and showed a progressive increase in intensity.", + "This was accompanied by constitutional symptoms like poor appetite and a general feeling of being unwell.", + "In view of the non-specific nature of the complaints, no further investigation was carried out and the patient was advised to attend regular follow-ups.", + "Enhanced CT and X-rays were performed after thorough clinical evaluation.", + "The CT scan revealed the malposition of a pedicle screw on both sides at the T11, T12, and L1 levels, which was a disaster.", + "The left side T12 and L1 malpositioned screws had exited the lateral pedicle cortex and were clearly abutting the posteromedial aspect of the descending thoracic aorta.", + "The formation of associated pseudoaneurysms in the thoracic aorta was noted.", + "The right side of T11 and both sides of T12 screws also had exited the lateral pedicle cortex and were abutting the wall of the pseudoaneurysm.", + "The left side screw in L2 perforated the lateral pedicle cortex but did not abut the aorta.", + "A re-surgery with the interdisciplinary collaboration of orthopaedics and vascular surgery teams was recommended and was subsequently performed in another hospital.", + "In the surgery, after the anesthesia and cardiopulmonary bypass, pseudoaneurysm and malpositioned screws were found under direct vision.", + "An ascending aorta replacement with artificial tissue was performed (Vascutek Ltd., diameter 16 × 8 mm, usable length 45 cm).", + "The extruded part of the pedicle screw was cut in situ so as to avoid any chance of re-injury.", + "The patient endured the surgery well and had a good recovery in his 4-month follow-up examination." + ], + "summary": "In this paper, we report here a case in which inadvertent injury to the thoracic aorta resulted in pseudoaneurysm, its manifestation was initially vague, resulting in a delayed diagnosis. Delayed aortic pseudoaneurysm or injury can be asymptomatic for a long time. Patients with renewed or continued back pain should alert orthopaedic surgeons regarding the possibility of pseudoaneurysms, regardless of the period that has elapsed after pedicle screw implantation.", + "summary_subclaims": [ + "Inadvertent injury to the thoracic aorta resulted in pseudoaneurysm.", + "The manifestation was initially vague, resulting in a delayed diagnosis.", + "Delayed aortic pseudoaneurysm or injury can be asymptomatic for a long time.", + "Patients with renewed or continued back pain should alert orthopaedic surgeons regarding the possibility of pseudoaneurysms.", + "This should be done regardless of the period that has elapsed after pedicle screw implantation." + ] + }, + { + "id": "multiclinsum_test_197_en.txt", + "fulltext": "A 11-year-old, 50-kg female with a diagnosis of CD10+ ALL was admitted to the hospital with fever and intermittent chest pain. The patient was in complete remission (CR) following SHOP-99 chemotherapy. At the time of hospital admission, she was receiving G-CSF for severe granulocytopenia post-intensification with cytarabine, and had also received broad-spectrum antibiotics and fluconazole prophylaxis during previous episodes of febrile neutropenia.\nThe physical examination was normal and the patient's general condition good. The blood examination showed 12,500 leukocytes/mm3 (82% neutrophils). An urine examination, a chest X-ray, and an abdominal ultrasonography did not reveal abnormal findings. Blood, urine, and stool cultures were also negative. She was initially treated with cefepime and teicoplanin. G-CSF was discontinued, after which the neutrophil count stabilized at around 1,700/mm3. CRP increased steadily up to 5.6 mg/dL despite broad-spectrum antibiotic therapy. One week later, while continuously febrile, the patient experienced worsening chest pain. A chest CT scan revealed several nodules 1 cm or smaller in diameter at the apex of both lungs . The Aspergillus galactomannan antigen was negative. Cultures of separate blood samples obtained percutaneously and from the central venous catheter, yielded Fusarium spp. The species of the infecting Fusarium could not be identified and in vitro susceptibility could not be tested. Liposomal amphotericin B (3 mg/kg/day) was then started. Although the dose of liposomal amphotericin B was increased to 5 mg/kg daily and the central venous catheter was removed (cultures of the catheter tip were sterile), the patient remained febrile and chest pain continued to worsen over the following 7 days. Blood cultures remained positive for Fusarium spp. and CRP levels increased up to 10.6 mg/dL . Caspofungin was then initiated (70-mg load followed by 50 mg daily). Fever disappeared within 48 hours of caspofungin onset . Chest pain improved significantly, blood cultures became negative, and CRP levels went down to the 1–2 mg/dL range over the following days. The patient presented two isolated fever spikes 8 and 12 days after the onset of caspofungin, which corresponded to a phlebitis episode and a limited reaction to L-asparaginase, respectively. Two weeks later, a new chest CT scan demonstrated progressive resolution of the lung nodules . Intravenous antifungals were discontinued and chemotherapy and suppressive therapy with oral voriconazole 200 mg twice daily was started. Three months later, a chest CT scan showed complete resolution of the pulmonary lesions, while the patient was asymptomatic . Thus, voriconazole was discontinued. Twenty-five months after discontinuation of all antifungal therapy, the patient remains healthy in the absence of any symptoms of fungal infection and in CR of her neoplastic disease.\nFusarium resistance to most antifungals and the severe immunosuppression-notably long-lasting, severe neutropenia – in oncohematological patients make Fusarium infections commonly fatal . Despite its low activity against Fusarium , amphotericin B remains the drug of choice. Voriconazole is licensed for the treatment of fusariosis based on in vitro data and a series of case reports with a reported response rate of ~40% . Posaconazole also has potential for therapy of systemic fusariosis . In any case, responses obtained with monotherapies remain too low and unsatisfactory.\nWe decided to treat our patient with amphotericin B and caspofungin for two reasons: (i) In our view amphotericin B remains the mainstay of therapy for fusariosis in pediatric patients; experience with voriconazole in this patient segment is limited [-]; (ii) Concurrent antifungal therapy is now generally considered an alternative way of improving outcome in difficult-to-treat invasive mycoses. In a recent in vitro study amphotericin B and voriconazole rendered mainly additive or subadditive interactions against Fusarium spp. . Yet, the concern remains that combining amphotericin B and azoles may lead to antagonism. In addition to the azole inhibition of the synthesis of amphotericin B's pharmacological target ergosterol, amphotericin B-related damage to the fungal cell membrane may interfere with the influx of azoles . In vitro caspofungin-inactive against Fusarium-showed synergistic or synergistic-to-additive interactions with amphotericin B for at least half of the Fusarium isolates . By inhibiting cell wall synthesis, caspofungin may presumably enhance the penetration of amphotericin B .\nWe hypothesize that combination antifungal therapy likely contributed to the sucessful treatment of our patient's severe invasive fusariosis, since clinical improvement only became evident after initiating caspofungin. Yet, the effect of caspofungin in the successful outcome of our case is not completely clear. The clinical response observed could also be the result of prolonged administration of liposomal amphotericin B and the lack of severe neutropenia. Finally, the administration of suppressive voriconazole and the early re-initiation of chemotherapy allowed by rapid infection control probably also contributed to the good long-term outcome. Of note, there have been a few case reports of response to caspofungin in combination with amphotericin B [,] and as monotherapy , although in some of these reports there was a clear association of response to recovery from neutropenia.", + "fulltext_subclaims": [ + "The patient was a 11-year-old, 50-kg female with CD10+ ALL.", + "The patient was in complete remission following SHOP-99 chemotherapy.", + "At the time of hospital admission, she was receiving G-CSF for severe granulocytopenia post-intensification with cytarabine.", + "She had also received broad-spectrum antibiotics and fluconazole prophylaxis during previous episodes of febrile neutropenia.", + "The physical examination was normal.", + "The patient's general condition was good.", + "The blood examination showed 12,500 leukocytes/mm3 (82% neutrophils).", + "An urine examination, a chest X-ray, and an abdominal ultrasonography did not reveal abnormal findings.", + "Blood, urine, and stool cultures were also negative.", + "She was initially treated with cefepime and teicoplanin.", + "G-CSF was discontinued, after which the neutrophil count stabilized at around 1,700/mm3.", + "CRP increased steadily up to 5.6 mg/dL despite broad-spectrum antibiotic therapy.", + "One week later, while continuously febrile, the patient experienced worsening chest pain.", + "A chest CT scan revealed several nodules 1 cm or smaller in diameter at the apex of both lungs.", + "The Aspergillus galactomannan antigen was negative.", + "Cultures of separate blood samples obtained percutaneously and from the central venous catheter, yielded Fusarium spp.", + "The species of the infecting Fusarium could not be identified.", + "In vitro susceptibility could not be tested.", + "Liposomal amphotericin B (3 mg/kg/day) was then started.", + "Although the dose of liposomal amphotericin B was increased to 5 mg/kg daily and the central venous catheter was removed (cultures of the catheter tip were sterile), the patient remained febrile and chest pain continued to worsen over the following 7 days.", + "Blood cultures remained positive for Fusarium spp.", + "CRP levels increased up to 10.6 mg/dL.", + "Caspofungin was then initiated (70-mg load followed by 50 mg daily).", + "Fever disappeared within 48 hours of caspofungin onset.", + "Chest pain improved significantly.", + "Blood cultures became negative.", + "CRP levels went down to the 1–2 mg/dL range over the following days.", + "The patient presented two isolated fever spikes 8 and 12 days after the onset of caspofungin, which corresponded to a phlebitis episode and a limited reaction to L-asparaginase, respectively.", + "Two weeks later, a new chest CT scan demonstrated progressive resolution of the lung nodules.", + "Intravenous antifungals were discontinued.", + "Chemotherapy and suppressive therapy with oral voriconazole 200 mg twice daily was started.", + "Three months later, a chest CT scan showed complete resolution of the pulmonary lesions.", + "The patient was asymptomatic.", + "Thus, voriconazole was discontinued.", + "Twenty-five months after discontinuation of all antifungal therapy, the patient remains healthy in the absence of any symptoms of fungal infection.", + "The patient remains in complete remission of her neoplastic disease.", + "Fusarium resistance to most antifungals and the severe immunosuppression-notably long-lasting, severe neutropenia – in oncohematological patients make Fusarium infections commonly fatal.", + "Despite its low activity against Fusarium, amphotericin B remains the drug of choice.", + "Voriconazole is licensed for the treatment of fusariosis based on in vitro data and a series of case reports with a reported response rate of ~40%.", + "Posaconazole also has potential for therapy of systemic fusariosis.", + "Responses obtained with monotherapies remain too low and unsatisfactory.", + "We decided to treat our patient with amphotericin B and caspofungin for two reasons.", + "In our view amphotericin B remains the mainstay of therapy for fusariosis in pediatric patients.", + "Experience with voriconazole in this patient segment is limited.", + "Concurrent antifungal therapy is now generally considered an alternative way of improving outcome in difficult-to-treat invasive mycoses.", + "In a recent in vitro study amphotericin B and voriconazole rendered mainly additive or subadditive interactions against Fusarium spp.", + "The concern remains that combining amphotericin B and azoles may lead to antagonism.", + "In vitro caspofungin-inactive against Fusarium-showed synergistic or synergistic-to-additive interactions with amphotericin B for at least half of the Fusarium isolates.", + "By inhibiting cell wall synthesis, caspofungin may presumably enhance the penetration of amphotericin B.", + "We hypothesize that combination antifungal therapy likely contributed to the successful treatment of our patient's severe invasive fusariosis.", + "The effect of caspofungin in the successful outcome of our case is not completely clear.", + "The clinical response observed could also be the result of prolonged administration of liposomal amphotericin B and the lack of severe neutropenia.", + "The administration of suppressive voriconazole and the early re-initiation of chemotherapy allowed by rapid infection control probably also contributed to the good long-term outcome.", + "There have been a few case reports of response to caspofungin in combination with amphotericin B.", + "There have been case reports of response to caspofungin as monotherapy.", + "In some of these reports there was a clear association of response to recovery from neutropenia." + ], + "summary": "We herein report a case of disseminated fusariosis diagnosed by chest CT scan and positive blood cultures to Fusarium spp. Because the patient's clinical condition deteriorated, CRP levels increased, and blood cultures continued to yield Fusarium spp. despite liposomal amphotericin B monotherapy up to 5 mg/kg daily, treatment with caspofungin was added. Within 2 weeks of onset of combined antifungal therapy, the chest CT scan demonstrated a progressive resolution of the pulmonary lesions. Upon discontinuation of intravenous antifungals, the patient received suppressive therapy with oral voriconazole. Three months later, a chest CT scan showed no abnormalities. Twenty-five months after discontinuation of all antifungal therapy, the patient remains in complete remission of her neoplastic disease with no signs of clinical activity of the Fusarium infection.", + "summary_subclaims": [ + "The patient was diagnosed with disseminated fusariosis.", + "Chest CT scan was used in the diagnosis.", + "Blood cultures were positive for Fusarium spp.", + "The patient's clinical condition deteriorated.", + "CRP levels increased.", + "Blood cultures continued to yield Fusarium spp. despite liposomal amphotericin B monotherapy up to 5 mg/kg daily.", + "Caspofungin was added to the treatment.", + "Within 2 weeks of onset of combined antifungal therapy, the chest CT scan demonstrated a progressive resolution of the pulmonary lesions.", + "Upon discontinuation of intravenous antifungals, the patient received suppressive therapy with oral voriconazole.", + "Three months later, a chest CT scan showed no abnormalities.", + "Twenty-five months after discontinuation of all antifungal therapy, the patient remains in complete remission of her neoplastic disease.", + "Twenty-five months after discontinuation of all antifungal therapy, there are no signs of clinical activity of the Fusarium infection." + ] + }, + { + "id": "multiclinsum_test_18_en.txt", + "fulltext": "A 47-year-old male patient suffering from mild abdominal pain for 2 months was admitted to our hospital in February 2018. He was diagnosed with “acute pancreatitis” first before transferring to our department. The ultrasound (US) and computed tomography (CT) scan of the abdomen revealed a pancreatic space-occupying lesion and pancreatic duct dilatation . The serum amylase and lipase levels were slightly elevated (231 and 546 U/L, respectively; normal range: 25–125 and 13–60 IU/L, respectively). the preoperative serum CA 19–9 level was 34.82 U/ml. Then, the patient underwent exploratory laparotomy. Intraoperative examination identified a hard mass in the body (approximately 4.0 cm × 3.0 cm) and tail of the pancreas, varicose veins around the spleen, a mass in the diaphragm (1.5 cm diameter), and three light masses on the surface of the liver. One mass was taken for pathological examination of the intraoperative rapid frozen section, and the result showed adenocarcinoma in the mass. The patient underwent radical distal pancreatectomy, splenectomy, diaphragm, and liver mass resection. The patient manifested with obstructive jaundice after surgery and gradually increased level of bilirubin. The total bilirubin increased from 65.4 μmol/L to 105.6 μmol/L and then to 140.1 μmol/L, and the direct bilirubin increased from 53.8 μmol/L to 81.0 μmol/L and then to 118.1 μmol/L. Subsequently, the patient underwent cholangiojejunostomy, and the pathological report revealed resected masses from the pancreas, liver, and diaphragm, indicating PTC metastases . Immunohistochemical studies showed positive stanning of TG(+), PAX-8(+), TTF-1(+), CK19(+), HBME-1(+), Galectin-3(+), P53(+), WT(+), DPC4(+), CA19–9(luminal surface+), MUC1(+), with negative staining of MUC5AC(−), MUC6(−), MUC2(−). Then, the patient had a thyroid US, which showed multiple hypoechoic masses in the left thyroid gland and an endoscopic US-guided fine needle aspiration (FNA) biopsy of the thyroid mass. Pathology also revealed papillary cancer. After the patient had recovered in the pancreatic department, he was transferred to the thyroid department. A CT scan was taken, and the result showed large masses in the isthmus and left lobes of the thyroid, multiple enlarged lymph nodes, and multiple masses in the bilateral parotid and submandibular gland . Then, the patient received an FNA biopsy of the parotid and submandibular mass, and the result showed PTC metastases. Immunohistochemical studies showed TTF-1(+), TG (−), CK19(+), HBME-1(+), Galectin-3(+), Villin(−), CDX-2(−). In July 2018, he received complete thyroidectomy, cervical lymphadenectomy, bilateral parotidectomy, bilateral submandibular gland and left recurrent laryngeal nerve resection. Intraoperative examination showed a huge irregular mass (approximately 10.0 cm × 7.0 cm × 5.0 cm) in the left and isthmus of the thyroid gland with calcification. The mass invaded the left recurrent laryngeal nerve and adhered to the surface of the trachea, and enlarged lymph nodes (3.5 and 2.5 cm in diameter) were found in the bilateral parotid. Multiple small enlarged lymph nodes (diameter ranging from 0.3 cm to 1.5 cm) were also noted in the bilateral submandibular gland. Intraoperative rapid frozen biopsy showed papillary cancer. The final histopathology revealed bilateral thyroid and isthmic papillary carcinoma and cervical lymph node metastasis, and papillary cancer in the left parotid and bilateral submandibular glands but not in the right parotid gland. Immunohistochemical studies showed CK19(+), HBME-1(+), Galectin-3(+), TG (partial+), TTF-1(+), P53(partial+), NapsinA (−), PD-L1(+, approximately 10%). The gene test showed activated mutation detected in the exon 15 of the BRAF gene (V600E) and the promoter 228 of TERT. After surgery, the patient was given radioiodine-131 therapy. He recovered well and was discharged from the hospital with oral Euthyrox therapy. The patient still survives at present.", + "fulltext_subclaims": [ + "The patient is a 47-year-old male.", + "The patient had mild abdominal pain for 2 months.", + "The patient was admitted to the hospital in February 2018.", + "The patient was diagnosed with 'acute pancreatitis' before transferring to the department.", + "The ultrasound and CT scan showed a pancreatic space-occupying lesion.", + "The ultrasound and CT scan showed pancreatic duct dilatation.", + "The serum amylase level was 231 U/L.", + "The serum lipase level was 546 U/L.", + "The preoperative serum CA 19–9 level was 34.82 U/ml.", + "The patient underwent exploratory laparotomy.", + "Intraoperative examination identified a hard mass in the body and tail of the pancreas.", + "Intraoperative examination identified a mass in the diaphragm.", + "Intraoperative examination identified three light masses on the surface of the liver.", + "The intraoperative rapid frozen section showed adenocarcinoma in the mass.", + "The patient underwent radical distal pancreatectomy.", + "The patient underwent splenectomy.", + "The patient underwent diaphragm and liver mass resection.", + "The patient manifested with obstructive jaundice after surgery.", + "The total bilirubin increased from 65.4 μmol/L to 105.6 μmol/L.", + "The direct bilirubin increased from 53.8 μmol/L to 81.0 μmol/L.", + "The patient underwent cholangiojejunostomy.", + "The pathological report showed PTC metastases.", + "The patient had a thyroid US showing multiple hypoechoic masses in the left thyroid gland.", + "The patient had an endoscopic US-guided FNA biopsy of the thyroid mass.", + "The FNA biopsy pathology showed papillary cancer.", + "The patient was transferred to the thyroid department after recovery.", + "A CT scan showed large masses in the isthmus and left lobes of the thyroid.", + "A CT scan showed multiple enlarged lymph nodes.", + "A CT scan showed multiple masses in the bilateral parotid and submandibular glands.", + "The patient had an FNA biopsy of the parotid and submandibular mass.", + "The FNA biopsy showed PTC metastases.", + "The patient received complete thyroidectomy.", + "The patient received cervical lymphadenectomy.", + "The patient received bilateral parotidectomy.", + "The patient received bilateral submandibular gland and left recurrent laryngeal nerve resection.", + "Intraoperative examination showed a huge irregular mass in the left and isthmus of the thyroid gland.", + "Intraoperative examination showed calcification in the thyroid mass.", + "Intraoperative examination showed the mass invaded the left recurrent laryngeal nerve.", + "Intraoperative examination showed enlarged lymph nodes in the bilateral parotid.", + "Intraoperative examination showed multiple small enlarged lymph nodes in the bilateral submandibular gland.", + "Intraoperative rapid frozen biopsy showed papillary cancer.", + "The final histopathology showed bilateral thyroid and isthmic papillary carcinoma.", + "The final histopathology showed cervical lymph node metastasis.", + "The final histopathology showed papillary cancer in the left parotid.", + "The final histopathology showed papillary cancer in the bilateral submandibular glands.", + "The final histopathology showed no papillary cancer in the right parotid gland.", + "The gene test showed an activated mutation in the exon 15 of the BRAF gene (V600E).", + "The gene test showed an activated mutation in the promoter 228 of TERT.", + "The patient received radioiodine-131 therapy.", + "The patient was discharged with oral Euthyrox therapy.", + "The patient still survives at present." + ], + "summary": "A 47-year-old male patient suffering from mild abdominal pain for 2 months was admitted to our hospital. The ultrasound (US) and computed tomography (CT) scan of the abdomen revealed a pancreatic space-occupying lesion and pancreatic duct dilatation, and the patient underwent exploratory laparotomy. Intraoperative examination identified a hard mass (approximately 4.0 cm × 3.0 cm) in the body and tail of the pancreas and a mass (1.5 cm in diameter) in the diaphragm. Three light masses were also noted on the surface of his liver. The patient underwent radical distal pancreatectomy, splenectomy, diaphragm, and liver mass resection. After surgery, the pathological report revealed that the masses resected from the pancreas, liver, and diaphragm were PTC metastases. Then, the patient had a thyroid US and an endoscopic US-guided fine needle aspiration biopsy of the thyroid mass. Pathology showed papillary cancer. Subsequently, the patient received a complete thyroidectomy, a cervical lymphadenectomy, bilateral parotidectomy, and bilateral submandibular gland resection.", + "summary_subclaims": [ + "The patient is a 47-year-old male.", + "The patient had mild abdominal pain for 2 months.", + "The ultrasound and CT scan of the abdomen revealed a pancreatic space-occupying lesion.", + "The ultrasound and CT scan of the abdomen revealed pancreatic duct dilatation.", + "The patient underwent exploratory laparotomy.", + "Intraoperative examination identified a hard mass in the body and tail of the pancreas.", + "The mass in the body and tail of the pancreas was approximately 4.0 cm × 3.0 cm.", + "Intraoperative examination identified a mass in the diaphragm.", + "The mass in the diaphragm was 1.5 cm in diameter.", + "Three light masses were noted on the surface of the liver.", + "The patient underwent radical distal pancreatectomy.", + "The patient underwent splenectomy.", + "The patient underwent diaphragm mass resection.", + "The patient underwent liver mass resection.", + "The pathological report revealed that the masses resected from the pancreas were PTC metastases.", + "The pathological report revealed that the masses resected from the liver were PTC metastases.", + "The pathological report revealed that the masses resected from the diaphragm were PTC metastases.", + "The patient had a thyroid ultrasound.", + "The patient had an endoscopic ultrasound-guided fine needle aspiration biopsy of the thyroid mass.", + "Pathology showed papillary cancer.", + "The patient received a complete thyroidectomy.", + "The patient received a cervical lymphadenectomy.", + "The patient received bilateral parotidectomy.", + "The patient received bilateral submandibular gland resection." + ] + }, + { + "id": "multiclinsum_test_260_en.txt", + "fulltext": "A 2-year-old girl, with a family history of early-onset cardiomyopathy and a medical history of recurrent upper respiratory tract infections necessitating only symptomatic care, visited her primary care pediatrician with symptoms of increasing lethargy, cough, shortness of breath after minimal exercise (such as walking, eating, and crying), puffy eyes, and edema in the lower extremities. Subsequently, she was referred to a pediatric cardiologist, who conducted an echocardiogram and baseline laboratory tests in a private clinic setting. The initial assessment revealed heart failure with a 30% ejection fraction. Following this diagnosis, the patient received outpatient treatment consisting of oral medications (Furosemide, Captopril, Spironolactone, Digoxin, and Carvedilol) and underwent frequent follow-up visits.\nDuring the 7-month period following the initial diagnosis, the patient's condition remained stable with no significant improvement or deterioration until one week prior to her presentation at our Emergency Department of the American University of Beirut Medical Center (AUBMC). At that time, she experienced frequent vomiting, worsening lethargy, and increased shortness of breath leading to a state of cardiogenic shock.\nOn presentation, she was ill-looking with mottled skin, cyanotic lips, cold extremities, weak peripheral pulses and delayed capillary refill time. She was afebrile, tachypneic, tachycardic, and hypotensive (respiratory rate (RR) of 60 breaths/minute, heart rate (HR) of 166 beats/minute, blood pressure (BP) of 78/31 mmHg and percutaneous oxygen saturation (SpO2) of 100% on face mask oxygen 5 liters/minute). Auscultation revealed faint heart sounds and diffuse rhonchi over the chest. Mild hepatomegaly was also noted.\nInitial laboratory assessment was consistent with severe metabolic and respiratory acidosis as shown by arterial blood gases (PH: 7.01; PCO2: 51 mmHg; Bicarbonate: 13 mmol/L; Base excess: -18 mmol/L; lactic acid: 9.8 mmol/L). Chest X-Ray revealed cardiomegaly with increased interstitial marking and EKG revealed first degree atrioventricular block . Echocardiogram on arrival showed severe biventricular systolic and diastolic dysfunction (ejection fraction less than 20%), with moderate bilateral atrioventricular valve regurgitation, left ventricular outflow tract velocity time integral (LVOT VTI) of 4 . Evidence of left ventricle diastolic dysfunction included a Mitral E/A ratio of 1.9, an E wave deceleration time of 35 msec, elevated systolic pressure in the pulmonary artery, PV A wave reversal exceeding the duration of the MV A wave, along with a severely dilated left atrium. A diagnosis of decompensated dilated cardiomyopathy with cardiogenic shock was made.\nPatient was intubated and started on Epinephrine drip, Milrinone drip and diuretics. She was admitted to Pediatric Intensive Care Unit (PICU) for extensive diagnostic workup and management where she received an advanced multidisciplinary care including cardiology, metabolic diseases, critical care, infectious diseases and nephrology specialists.\nShe remained intubated and mechanically ventilated throughout her hospital stay. Serial echocardiographic assessments revealed worsening ventricular function (EF less than 17%), despite various cardiac medications (Epinephrine, Norepinephrine, Milrinone, Dobutamine, Digoxin, Carvedilol), and aggressive diuresis (Furosemide, Spironolactone, Acetazolamide, Hydrochlorothiazide, Bumetanide). Two doses of intravenous Levosimendan infusions were also administered; the third dose was stopped due to transient hypotension.\nMetabolic and genetic work up was done and was negative. Whole exome sequencing later revealed a homozygous mutation in the MYL3 (Myosin Light Chain 3) gene, associated with familial autosomal dominant MYL3-related cardiomyopathy.\nHer hospital stay was complicated by multiple infections including multilobar pneumonia and candiduria, for which she received broad spectrum antibiotics and antifungals. Progressively, the child’s condition continued to deteriorate as she developed end-organ dysfunction, including renal and hepatic failure with severe lactic acidosis and disseminated intravascular coagulation. After a total of 70 days of hospitalization, the patient developed rare ectopic beats then went into cardiac arrest followed by a cessation of electrical and mechanical activity of the heart, despite cardiopulmonary resuscitative efforts.", + "fulltext_subclaims": [ + "The patient is a 2-year-old girl.", + "The patient has a family history of early-onset cardiomyopathy.", + "The patient has a medical history of recurrent upper respiratory tract infections.", + "The patient's upper respiratory tract infections were managed with only symptomatic care.", + "The patient visited her primary care pediatrician with symptoms of increasing lethargy.", + "The patient had shortness of breath after minimal exercise.", + "The patient had edema in the lower extremities.", + "The patient was referred to a pediatric cardiologist.", + "The pediatric cardiologist conducted an echocardiogram.", + "The initial assessment revealed heart failure with a 30% ejection fraction.", + "The patient received outpatient treatment consisting of oral medications.", + "The patient's condition remained stable for 7 months following the initial diagnosis.", + "One week prior to her presentation at the Emergency Department, the patient experienced frequent vomiting.", + "On presentation, the patient was ill-looking with mottled skin.", + "The patient was afebrile.", + "The patient's heart rate was 166 beats/minute.", + "The patient's blood pressure was 78/31 mmHg.", + "Auscultation revealed faint heart sounds.", + "The initial laboratory assessment showed a pH of 7.01.", + "The initial laboratory assessment showed a bicarbonate level of 13 mmol/L.", + "The EKG revealed first degree atrioventricular block.", + "The echocardiogram on arrival showed severe biventricular systolic and diastolic dysfunction.", + "The echocardiogram showed an ejection fraction less than 20%.", + "The diagnosis was decompensated dilated cardiomyopathy with cardiogenic shock.", + "The patient was intubated.", + "The patient was started on Epinephrine drip.", + "The patient was admitted to the Pediatric Intensive Care Unit.", + "Serial echocardiographic assessments revealed worsening ventricular function.", + "The patient received two doses of intravenous Levosimendan infusions.", + "The third dose of Levosimendan was stopped due to transient hypotension.", + "Whole exome sequencing revealed a homozygous mutation in the MYL3 gene.", + "The patient developed multilobar pneumonia.", + "The patient developed end-organ dysfunction.", + "The patient developed disseminated intravascular coagulation.", + "The patient had a total hospital stay of 70 days.", + "The patient went into cardiac arrest.", + "Cardiopulmonary resuscitative efforts were performed." + ], + "summary": "We report the case of a 2-year-old girl diagnosed with dilated cardiomyopathy associated with homozygous mutation in the Myosin Light Chain 3 gene admitted for edema in lower extremities, muscle weakness, lethargy and vomiting, and she was found to be in cardiogenic shock. Chest x-ray showed cardiomegaly and EKG showed first degree atrioventricular block. Echocardiogram showed severe biventricular systolic and diastolic dysfunction. After 70 days of hospitalization, the patient went into cardiac arrest with cessation of electrical and mechanical activity of the heart, despite cardiopulmonary resuscitative efforts.", + "summary_subclaims": [ + "The patient was a 2-year-old girl.", + "The patient was diagnosed with dilated cardiomyopathy.", + "The patient had a homozygous mutation in the Myosin Light Chain 3 gene.", + "The patient was admitted for edema in lower extremities.", + "The patient was admitted for muscle weakness.", + "The patient was admitted for lethargy.", + "The patient was admitted for vomiting.", + "The patient was found to be in cardiogenic shock.", + "Chest x-ray showed cardiomegaly.", + "EKG showed first degree atrioventricular block.", + "Echocardiogram showed severe biventricular systolic and diastolic dysfunction.", + "The patient was hospitalized for 70 days.", + "The patient went into cardiac arrest.", + "The patient had cessation of electrical and mechanical activity of the heart.", + "Cardiopulmonary resuscitative efforts were performed." + ] + }, + { + "id": "multiclinsum_test_1049_en.txt", + "fulltext": "The patient was a 29-year-old man admitted to the hospital four years ago (June 2009) due to hematemesis. The problem was diagnosed as esophageal variceal bleeding and the proper treatment was provided. He had no history of alcohol consumption or diabetes mellitus. Moreover, the tests were negative for all types of viral hepatitis (B, C), EBV (Epstein–Barr virus), herpes, CMV (Cytomegalovirus), autoimmune hepatitis, HIV, celiac and Wilson’s disease. The colonoscopy result was normal. On April 2010, liver biopsy showed cirrhotic changes and the patient was diagnosed with cryptogenic cirrhosis. His name went to the list of liver transplantation candidates and the academic management for cirrhotic patients was started for him.\nThe patient first visited Behesht Clinic of Tehran University of Medical Sciences in Tehran for Iranian traditional medicine on September 2011, about 17 months after being diagnosed. At the time, his medicinal prescription included spironolactone, propranolol, prednisolone and doxepin. The patient stopped taking all the medications after one month.\nHis height was 173 cm and his weight was 57 kg. In his first visit, he had flatulence, dyspepsia, and heartburn. He was generally thirsty and drank up to eight glasses of cold water a day. He also had severe itching sensation of skin and would not sweat even during intense physical activities. His sclera was icteric.\nFrom his first visit to Behesht Clinic on September 2011 till February 2013, the patient was visited 16 times and each time, considering his general state and by performing physical examinations, the necessary traditional medication was prescribed for him. After three weeks of treatment, his itching sensation was significantly reduced, he felt energetic, and his flatulence and heartburn decreased. During four months of treatment, the patient gained 6 kg without any sign of ascites in abdominal ultrasonography. From the first admission (June 2009) until the end of study (February 2013), the alpha-fetoprotein (AFP) level was always in the normal range. The traditional medicine preparations used for this patient were based on the book “Al-Qanoon fi al-Tibb” by Avicenna. What follows is a list of different medicines used at different stages of the treatment:\nMonzeje soda, kabed capsuls, sekanjebine-bozoori, sekanjebine-sadri, samgh capsuls, eksir syrup, khabasolhadid, goleghand, habolroman, javareshe amole, aftimoon syrup, araghe-kasni shahtare, araghe-zenyan. and show the changes in the patient’s test results before and after the traditional medication. At the moment, the patient is in a good general condition and there is no need for liver transplantation.", + "fulltext_subclaims": [ + "The patient was a 29-year-old man admitted to the hospital four years ago (June 2009) due to hematemesis.", + "The problem was diagnosed as esophageal variceal bleeding.", + "The proper treatment was provided.", + "He had no history of alcohol consumption.", + "He had no history of diabetes mellitus.", + "The tests were negative for all types of viral hepatitis (B, C).", + "The tests were negative for EBV (Epstein–Barr virus).", + "The tests were negative for herpes.", + "The tests were negative for CMV (Cytomegalovirus).", + "The tests were negative for autoimmune hepatitis.", + "The tests were negative for HIV.", + "The tests were negative for celiac disease.", + "The tests were negative for Wilson’s disease.", + "The colonoscopy result was normal.", + "On April 2010, liver biopsy showed cirrhotic changes.", + "The patient was diagnosed with cryptogenic cirrhosis.", + "His name went to the list of liver transplantation candidates.", + "The academic management for cirrhotic patients was started for him.", + "The patient first visited Behesht Clinic of Tehran University of Medical Sciences in Tehran for Iranian traditional medicine on September 2011.", + "At the time, his medicinal prescription included spironolactone.", + "At the time, his medicinal prescription included propranolol.", + "At the time, his medicinal prescription included prednisolone.", + "At the time, his medicinal prescription included doxepin.", + "The patient stopped taking all the medications after one month.", + "His height was 173 cm.", + "His weight was 57 kg.", + "In his first visit, he had flatulence.", + "In his first visit, he had dyspepsia.", + "In his first visit, he had heartburn.", + "He was generally thirsty and drank up to eight glasses of cold water a day.", + "He had severe itching sensation of skin.", + "He would not sweat even during intense physical activities.", + "His sclera was icteric.", + "From his first visit to Behesht Clinic on September 2011 till February 2013, the patient was visited 16 times.", + "After three weeks of treatment, his itching sensation was significantly reduced.", + "After three weeks of treatment, he felt energetic.", + "After three weeks of treatment, his flatulence and heartburn decreased.", + "During four months of treatment, the patient gained 6 kg.", + "During four months of treatment, there was no sign of ascites in abdominal ultrasonography.", + "From the first admission (June 2009) until the end of study (February 2013), the alpha-fetoprotein (AFP) level was always in the normal range.", + "The traditional medicine preparations used for this patient were based on the book “Al-Qanoon fi al-Tibb” by Avicenna.", + "The patient is in a good general condition.", + "There is no need for liver transplantation." + ], + "summary": "The study case was a 29-year-old man, admitted to the hospital four years ago due to esophageal variceal hemorrhage. A biopsy of his liver showed cryptogenic cirrhosis; thus, he was a candidate for liver transplant. The patient visited the outpatient Iranian traditional medicine center, Behesht Clinic, in Tehran, Iran, two years after his bleeding course and began treatment with traditional herbal medicine. In the following month, he stopped taking his previous medications. During the 18-month follow up, he was visited 16 times. During this time, his general health improved and his hemoglobin level increased. Based on the ultrasound reports, the spleen size, the gallbladder wall edema, and the portal vein diameter decreased. Even though the ascites disappeared, the patient gained weight. His model for end-stage liver disease (MELD) score reduced from 10 (prior to the Iranian traditional medicine treatment) to 8. The bilirubin level decreased as well. The alanine aminotransferase (ALT) and aspartate aminotransferase (AST) levels increased and the serum albumin level and platelet count decreased.", + "summary_subclaims": [ + "The study case was a 29-year-old man.", + "He was admitted to the hospital four years ago due to esophageal variceal hemorrhage.", + "A biopsy of his liver showed cryptogenic cirrhosis.", + "He was a candidate for liver transplant.", + "The patient visited the outpatient Iranian traditional medicine center, Behesht Clinic, in Tehran, Iran, two years after his bleeding course.", + "He began treatment with traditional herbal medicine.", + "In the following month, he stopped taking his previous medications.", + "During the 18-month follow up, he was visited 16 times.", + "Based on the ultrasound reports, the spleen size decreased.", + "Based on the ultrasound reports, the gallbladder wall edema decreased.", + "Based on the ultrasound reports, the portal vein diameter decreased.", + "The ascites disappeared.", + "The patient gained weight.", + "The MELD score reduced from 10 (prior to the Iranian traditional medicine treatment) to 8.", + "The bilirubin level decreased.", + "The alanine aminotransferase (ALT) and aspartate aminotransferase (AST) levels increased.", + "The serum albumin level decreased.", + "The platelet count decreased." + ] + }, + { + "id": "multiclinsum_test_2128_en.txt", + "fulltext": "A 32-year old gentleman was admitted to our trauma department with a painful, immobile right knee. He sustained the injury externally rotating his knee whilst in “slight flexion” while he was moving from the driver’s seat to the passenger’s seat of his car. He had a history of two previous lateral patellar dislocations on same knee. The first event was 15 years prior, when his knee twisted in flexed position while pushing a car. He was taken to the emergency department where it was successfully reduced under sedation. The second event was four years prior, when he sustained an injury while pushing a van, this time with the right knee fully extended. On this occasion, his patella spontaneously reduced and he did not seek any medical intervention. Our patient had no other significant past medical or surgical history and explained his right knee was completely asymptomatic prior to this current event.\nOn examination, there was an obvious deformity suggesting lateral displacement of the patella with a sulcus in the skin evident over the femoral groove. Furthermore, the knee was held fixed in 15 degrees of flexion. Due to patient positioning difficulties we were unable to obtain true AP and lateral views on X-ray. The radiographs demonstrated a laterally displaced and a mal-rotated patella in the vertical plane (see Figs. and ). A manipulation under sedation was attempted unsuccessfully. A further attempt of reduction under a femoral nerve block had again been unsuccessful.\nOur patient was subsequently taken to theatre where one final attempt of closed reduction was carried out under general anaesthetic and muscle relaxation. Ultimately, this failed and an open reduction was performed. The patient was positioned supine and an anterior midline skin incision was used. Complete rupture of the medial patellofemoral ligament (MPFL) was identified with the patella situated lateral to the lateral femoral condyle, everted by approximately 100 degrees. There were no visible deficiencies of the femoral condyles or the patellar articular surface. The patella was carefully reduced by direct manipulation. Following manipulation, the knee joint was washed out with normal saline and the medial patella retinaculum was repaired. After the repair, patella tracking was satisfactory with full range of flexion and extension. Post-operative radiographs confirm the patella in a satisfactory position in the antero-posterior and lateral planes (see Figs. and ). The patient was placed in an extension splint for comfort purposes immediately post-operatively. No weight bearing restrictions were applied. Early mobilization was encouraged after 5 days and the patient was referred for early physiotherapy. At 3 months follow-up, our patient had no further episodes of dislocation, full range of knee extension and flexion, and normal patella tracking. A hypermobility assessment at this stage revealed a Beighton score of 2 with extension beyond 10 degrees of both elbows only.", + "fulltext_subclaims": [ + "The patient is a 32-year old gentleman.", + "He was admitted to the trauma department with a painful, immobile right knee.", + "He sustained the injury externally rotating his knee whilst in 'slight flexion' while moving from the driver’s seat to the passenger’s seat of his car.", + "He had a history of two previous lateral patellar dislocations on the same knee.", + "The first dislocation was 15 years prior, when his knee twisted in flexed position while pushing a car.", + "The first dislocation was successfully reduced under sedation in the emergency department.", + "The second dislocation was four years prior, when he sustained an injury while pushing a van.", + "The second dislocation occurred with the right knee fully extended.", + "The second dislocation resolved with spontaneous reduction and he did not seek medical intervention.", + "He had no other significant past medical or surgical history.", + "His right knee was completely asymptomatic prior to this current event.", + "On examination, there was an obvious deformity suggesting lateral displacement of the patella.", + "A sulcus in the skin was evident over the femoral groove.", + "The knee was held fixed in 15 degrees of flexion.", + "Due to patient positioning difficulties, true AP and lateral views on X-ray could not be obtained.", + "The radiographs demonstrated a laterally displaced and mal-rotated patella in the vertical plane.", + "A manipulation under sedation was attempted but was unsuccessful.", + "A further attempt of reduction under a femoral nerve block was also unsuccessful.", + "The patient was taken to theatre for a final attempt of closed reduction under general anaesthetic and muscle relaxation.", + "This attempt failed and an open reduction was performed.", + "The patient was positioned supine and an anterior midline skin incision was used.", + "Complete rupture of the medial patellofemoral ligament (MPFL) was identified.", + "The patella was situated lateral to the lateral femoral condyle and everted by approximately 100 degrees.", + "There were no visible deficiencies of the femoral condyles or the patellar articular surface.", + "The patella was reduced by direct manipulation.", + "The knee joint was washed out with normal saline.", + "The medial patella retinaculum was repaired.", + "Post-operative radiographs confirmed the patella in a satisfactory position in the antero-posterior and lateral planes.", + "The patient was placed in an extension splint for comfort purposes immediately post-operatively.", + "No weight bearing restrictions were applied.", + "Early mobilization was encouraged after 5 days.", + "The patient was referred for early physiotherapy.", + "At 3 months follow-up, the patient had no further episodes of dislocation.", + "At 3 months follow-up, the patient had full range of knee extension and flexion.", + "At 3 months follow-up, the patient had normal patella tracking.", + "A hypermobility assessment at 3 months revealed a Beighton score of 2.", + "The hypermobility assessment showed extension beyond 10 degrees of both elbows only." + ], + "summary": "A 32-year old gentleman presented with an irreducible patella dislocation following an unusual atraumatic mechanism. Following attempts at closed reduction under sedation and regional nerve block, eventual open reduction and soft tissue reconstruction was required under general anesthetic. During the open reduction procedure, it was noted that the patella had dislocated into a lateral extra-articular position and rotated around its vertical axis. Following patella reduction, the medial patellar retinaculum was repaired. Examination under anesthetic revealed satisfactory tracking of patella following repair.", + "summary_subclaims": [ + "The patient is a 32-year old gentleman.", + "The patient presented with an irreducible patella dislocation.", + "The patella dislocation occurred following an unusual atraumatic mechanism.", + "Closed reduction under sedation and regional nerve block was attempted.", + "Open reduction and soft tissue reconstruction was required under general anesthetic.", + "During the open reduction procedure, the patella had dislocated into a lateral extra-articular position.", + "During the open reduction procedure, the patella had rotated around its vertical axis.", + "Following patella reduction, the medial patellar retinaculum was repaired.", + "Examination under anesthetic revealed satisfactory tracking of patella following repair." + ] + }, + { + "id": "multiclinsum_test_2009_en.txt", + "fulltext": "A 50-year-old housewife presented in the emergency department of our level 1 trauma center with complaints of pain and immobility of the left hip joint and inability to bear weight forthe past 20 days. She gave a history of bilateral anterior groin pain (left > right) for thepast 4 months. She also had a history of limping, difficulty in sitting cross-legged, and squatting for the same period. The pain was insidious in onset and progressed over time to make her bedridden. On examination, there was tenderness over bilateral hip joints (left > right), external rotation deformity, and 1cm shortening of the left lower limb. Movement of the left hip joint was extremely painful and was not encouraged. There was pain at extremes of motion of the right hip joint. The patient was able to do straight leg raise on the right side but not on the left side. Neurovascular examination was bilaterally unremarkable. The patient had no comorbidities and was not on any long-term medication. There was no history of trauma (trivial or overt), excessive physical activity, or fragility fractures in the past. The patient was postmenopausal for2 years. The patient was actively mobile before the onset of symptoms. She consulted a local practitioner during initial stages of her discomfort who had prescribed her NSAIDs. However, there was no relief and pain progressed to such an extent that she was not able to bear weight. A 20 days earlier anteroposterior pelvis with bilateral hip radiograph showed sclerosis over bilateral inferomedial femoral neck with cortical breach in the right side and an undisplaced complete fracture line over the left side. The neck shaft angle was 130° on the right side and 114° on the left side. Plain radiographs were orderedon presentation which showed a displaced fracture neck of femur on the left side collapsed in varus and sclerosis over inferomedial aspect of the right femoral neck with cortical breach. A computed tomography scan confirmed the X-ray diagnosis . Blood investigations showed a normal calcium profile, Vitamin D, and serum parathyroid hormone levels. DEXA scan showed normal t- and z-scores in hip and spine. Whole spine radiographs revealed no abnormalities. Thus, a diagnosis of bilateral FNSFs was made and the patient was admitted for surgical stabilization. She underwent osteosynthesis with three cannulated screws on the right side and 2 days later underwent total hip arthroplasty for displaced fracture on the left side . Postoperatively, she was allowed full weight-bearing mobilization on the left side and toe touch on the right side. There were no post-operative complications. Radiographs were repeated at 3 weeks, 6 weeks, 3 months, 6 months, and 1 year postoperatively which showed union at the right side with no further varus collapse or implant failure . The left side with hip prosthesis was also normal. At 1-year follow-up, the patient was pain free, able to walk full weight-bearing without support and carry out her daily activities comfortably.", + "fulltext_subclaims": [ + "The patient is a 50-year-old housewife.", + "She presented with pain and immobility of the left hip joint.", + "She had a 4-month history of bilateral anterior groin pain.", + "The pain was left greater than right.", + "She had a 4-month history of limping.", + "She had difficulty in sitting cross-legged for the same period.", + "The pain was insidious in onset.", + "The pain progressed to make her bedridden.", + "On examination, there was tenderness over bilateral hip joints.", + "There was 1cm shortening of the left lower limb.", + "Movement of the left hip joint was extremely painful.", + "There was pain at extremes of motion of the right hip joint.", + "The patient was able to do straight leg raise on the right side.", + "Neurovascular examination was bilaterally unremarkable.", + "The patient had no comorbidities.", + "There was no history of trauma.", + "The patient was postmenopausal for 2 years.", + "A 20 days earlier anteroposterior pelvis with bilateral hip radiograph showed sclerosis over bilateral inferomedial femoral neck.", + "The radiograph showed an undisplaced complete fracture line over the left side.", + "The neck shaft angle was 130° on the right side.", + "The neck shaft angle was 114° on the left side.", + "Plain radiographs showed a displaced fracture neck of femur on the left side.", + "A computed tomography scan confirmed the X-ray diagnosis.", + "Blood investigations showed a normal calcium profile.", + "Blood investigations showed normal Vitamin D levels.", + "Blood investigations showed normal serum parathyroid hormone levels.", + "DEXA scan showed normal t- and z-scores in hip and spine.", + "Whole spine radiographs revealed no abnormalities.", + "A diagnosis of bilateral FNSFs was made.", + "The patient underwent osteosynthesis with three cannulated screws on the right side.", + "The patient underwent total hip arthroplasty for displaced fracture on the left side.", + "Postoperatively, she was allowed full weight-bearing mobilization on the left side.", + "Postoperatively, she was allowed toe touch on the right side.", + "Radiographs at 1 year postoperatively showed union at the right side.", + "Radiographs showed no further varus collapse or implant failure.", + "The left side with hip prosthesis was also normal.", + "At 1-year follow-up, the patient was pain free.", + "At 1-year follow-up, the patient was able to walk full weight-bearing without support." + ], + "summary": "We present a case of bilateral neck of femur stress fracture (compression type) in a healthy 50-year-old housewife treated with osteosynthesis with three cannulated screws on one side and total hip replacement on other sides. Follow-up at 1 year revealed optimum results.", + "summary_subclaims": [ + "The patient is a 50-year-old housewife.", + "The patient had bilateral neck of femur stress fractures.", + "The fractures were compression type.", + "The patient was treated with osteosynthesis with three cannulated screws on one side.", + "The patient was treated with total hip replacement on the other side.", + "Follow-up at 1 year revealed optimum results." + ] + }, + { + "id": "multiclinsum_test_9_en.txt", + "fulltext": "A 75-year-old woman received denosumab for the 1st time in October 2018 for severe postmenopausal osteoporosis. She had no history of other medication use for osteoporosis. Osteoporosis was diagnosed both clinically and radiographically . She had no nutritional deficiencies or family history of osteoporosis. She had undergone a hybrid THA because of developmental dysplasia of the right hip in 2006. At our hospital, she received denosumab 60 mg per dose, for a total of six doses. Meanwhile, colon cancer was detected in August 2019, and she underwent endoscopic surgery in September 2019. She also underwent positron emission tomography, which showed no metastasis, after which she underwent regular follow-ups without any anticancer drugs. No regular medications were prescribed for other diseases. She had been generally healthy otherwise. In May 2021, she experienced slight weight-bearing pain in the right hip with no antecedent trauma. Radiographs at the time of THA in 2006 and at the time of denosumab administration for the 1st time in 2018 showed no pathological changes in the femoral shaft around the stem ; however, there was an apparent transverse fracture line with lateral cortical thickening when she felt pain in the right thigh . Computed tomography revealed femoral cortical reactions more clearly . She had not received systemic glucocorticoids and proton-pump inhibitors, which had been listed as drugs that affect the bones in a previous study . A diagnosis of denosumab-associated atypical periprosthetic fracture was made. She underwent revision surgery for conversion to a longer cemented stem . 10 months later, the fracture site healed and she was possible to walk no cane at the latest visit in August 2022.", + "fulltext_subclaims": [ + "The patient is a 75-year-old woman.", + "She received denosumab for the 1st time in October 2018.", + "The indication was severe postmenopausal osteoporosis.", + "She had no history of other medication use for osteoporosis.", + "Osteoporosis was diagnosed both clinically and radiographically.", + "She had no nutritional deficiencies.", + "She had no family history of osteoporosis.", + "She had undergone a hybrid THA because of developmental dysplasia of the right hip in 2006.", + "At our hospital, she received denosumab 60 mg per dose.", + "She received a total of six doses.", + "Colon cancer was detected in August 2019.", + "She underwent endoscopic surgery in September 2019.", + "Positron emission tomography showed no metastasis.", + "She underwent regular follow-ups without any anticancer drugs.", + "No regular medications were prescribed for other diseases.", + "In May 2021, she experienced slight weight-bearing pain in the right hip.", + "Radiographs at the time of THA in 2006 showed no pathological changes in the femoral shaft around the stem.", + "Radiographs at the time of denosumab administration for the 1st time in 2018 showed no pathological changes in the femoral shaft around the stem.", + "There was an apparent transverse fracture line with lateral cortical thickening when she felt pain in the right thigh.", + "Computed tomography revealed femoral cortical reactions more clearly.", + "She had not received systemic glucocorticoids.", + "She had not received proton-pump inhibitors.", + "A diagnosis of denosumab-associated atypical periprosthetic fracture was made.", + "She underwent revision surgery for conversion to a longer cemented stem.", + "10 months later, the fracture site healed.", + "She was possible to walk no cane at the latest visit in August 2022." + ], + "summary": "Herein, a 75-year-old woman suffered an atypical periprosthetic femoral fracture 31 months after receiving denosumab. The fracture occurred transverse to the stem tip with lateral cortical thickening. The patient underwent revision surgery for conversion to a longer cemented stem. The fracture site healed 10 months after revision surgery.", + "summary_subclaims": [ + "A 75-year-old woman suffered an atypical periprosthetic femoral fracture 31 months after receiving denosumab.", + "The fracture occurred transverse to the stem tip with lateral cortical thickening.", + "The patient underwent revision surgery for conversion to a longer cemented stem.", + "The fracture site healed 10 months after revision surgery." + ] + }, + { + "id": "multiclinsum_test_433_en.txt", + "fulltext": "A 43-year-old, previously healthy Caucasian female presented to her general practitioner with a few-months history of left knee pain. She had also noticed a left-sided supraclavicular fossa (SCF) mass. She had no significant medical history, never smoked, with moderate alcohol intake. A maternal grandmother had endometrial cancer aged 65 years.\nAn ultrasound-guided core biopsy of the suspicious SCF mass was urgently arranged. Review by an expert soft tissue pathologist revealed grade 2 leiomyosarcoma, with immunohistochemistry positive for desmin, smooth muscle actin and h-caldesmon. CT and PET-CT imaging showed extensive metastatic disease, with no clear primary site. There were widespread cutaneous, subcutaneous, soft tissue, lung, liver, right adrenal and peritoneal metastases. A lytic lesion involving the left femoral head was identified as at risk for pathological fracture and a likely cause of the patient’s longstanding left knee pain. She initially underwent urgent prophylactic stabilisation of the left femur, followed by radiotherapy.\nShe commenced first-line palliative doxorubicin chemotherapy. The patient was noted to have a mild erythematous maculopapular rash on her face and upper chest in sun-exposed areas at her pre-treatment consultation. This developed several days following femoral surgery and persisted for a few weeks. No drug, environmental or infective triggers were identified. The rash was treated with topical hydrocortisone 1% and emollient cream (diprobase), and resolved during cycle one of doxorubicin with a sustained remission throughout chemotherapy. She did not report any muscle weakness or pain during this time. Six cycles of doxorubicin were well tolerated, with one episode of febrile neutropenia requiring a 25% dose reduction. Imaging assessment at the end of chemotherapy showed overall stable metastatic disease by RECIST 1.1 criteria , with a minor reduction in some metastatic deposits noted mid-treatment.\nTwo months later, the patient presented acutely unwell to her local hospital with a new-onset rash in a shawl-like distribution (upper chest, neck and arms), with flagellate erythema and associated periorbital oedema and proximal limb weakness. The patient denied breathing or swallowing difficulty. On examination periungual erythema and Gottron’s papules were noted, without visible dilated capillary nailfold loops. There was reduced proximal power in both upper and lower limb (3–4/5), but no neck or truncal weakness. Vital signs found she was tachycardic and febrile. Routine blood tests on admission showed c-reactive protein < 4 and mildly raised white cell count 11.4 (normal range 4–11 × 109L). Alanine aminotransferase (ALT) was mildly raised at 61 (normal 10–49 U/L) with unremarkable renal function. Blood cultures grew Staphylococcus hominis and she was treated with intravenous antibiotics and appropriate medical management.\nRheumatology and dermatology review led to the diagnosis of dermatomyositis, likely paraneoplastic, in the context of known metastatic leiomyosarcoma. Investigation supporting this included; raised creatinine kinase (CK) and erythrocyte sediment rate at 695 (normal range 25–200 U/L) and 32 (normal range 0–27 mm/h) respectively. Autoantibody screen negative for ENA, dsDNA, anti-CCP, with normal complement levels and weakly positive ANA (1:160). Myositis antibody panel was positive for transcription intermediary factor-1 gamma (TIF1γ) antibodies alone, whilst anti-Jo1 and anti-Mi2 antibody negative. In addition to intramuscular metastatic disease, MRI femur showed mild increased signal within the muscles compatible with myositis. An echocardiogram confirmed normal cardiac function. Electromyography (EMG) found myopathic changes of moderate degree in lower and upper limbs, worse in the lower limbs with proximal predominance. The findings were in keeping with a diagnosis of proximal myopathy. Right chest punch biopsy histology was consistent with dermatomyositis. Muscle biopsy was not performed, given the potential risk of metastatic disease seeding.\nTreatment was commenced with a weaning course of prednisolone (initial dose 40 mg daily) and topical clobetasol 0.05% with clinical improvement in both weakness and rash over several months. Diagnosis of paraneoplastic dermatomyositis triggered re-evaluation of the patient’s leiomyosarcoma with CT imaging, which showed multifocal progression. Second-line chemotherapy with trabectedin was commenced following recovery from the acute admission and once the dermatomyositis was controlled with steroid therapy. Systemic anti-cancer therapy was again associated with mild improvement in dermatomyositis symptoms.", + "fulltext_subclaims": [ + "The patient is a 43-year-old, previously healthy Caucasian female.", + "She had a few-months history of left knee pain.", + "She had noticed a left-sided supraclavicular fossa (SCF) mass.", + "She had no significant medical history.", + "A maternal grandmother had endometrial cancer aged 65 years.", + "An ultrasound-guided core biopsy of the suspicious SCF mass was urgently arranged.", + "Review by an expert soft tissue pathologist revealed grade 2 leiomyosarcoma.", + "Immunohistochemistry was positive for desmin, smooth muscle actin and h-caldesmon.", + "CT and PET-CT imaging showed extensive metastatic disease, with no clear primary site.", + "There were widespread cutaneous, subcutaneous, soft tissue, lung, liver, right adrenal and peritoneal metastases.", + "A lytic lesion involving the left femoral head was identified as at risk for pathological fracture.", + "She initially underwent urgent prophylactic stabilisation of the left femur.", + "She commenced first-line palliative doxorubicin chemotherapy.", + "She had a mild erythematous maculopapular rash on her face and upper chest in sun-exposed areas at her pre-treatment consultation.", + "The rash developed several days following femoral surgery.", + "The rash was treated with topical hydrocortisone 1% and emollient cream (diprobase).", + "The rash resolved during cycle one of doxorubicin.", + "She did not report any muscle weakness or pain during this time.", + "Six cycles of doxorubicin were well tolerated.", + "There was one episode of febrile neutropenia requiring a 25% dose reduction.", + "Imaging assessment at the end of chemotherapy showed overall stable metastatic disease by RECIST 1.1 criteria.", + "Two months later, the patient presented acutely unwell with a new-onset rash in a shawl-like distribution.", + "The rash was associated with flagellate erythema, periorbital oedema and proximal limb weakness.", + "On examination, periungual erythema and Gottron’s papules were noted.", + "There was reduced proximal power in both upper and lower limbs.", + "Routine blood tests showed a mildly raised white cell count of 11.4 × 10^9/L.", + "Blood cultures grew Staphylococcus hominis.", + "Rheumatology and dermatology review led to the diagnosis of dermatomyositis.", + "The dermatomyositis was likely paraneoplastic in the context of known metastatic leiomyosarcoma.", + "Investigation showed raised creatinine kinase (CK) at 695 U/L.", + "The myositis antibody panel was positive for transcription intermediary factor-1 gamma (TIF1γ) antibodies alone.", + "MRI femur showed mild increased signal within the muscles compatible with myositis.", + "Electromyography (EMG) found myopathic changes of moderate degree in lower and upper limbs.", + "Right chest punch biopsy histology was consistent with dermatomyositis.", + "Treatment was commenced with a weaning course of prednisolone (initial dose 40 mg daily).", + "Diagnosis of paraneoplastic dermatomyositis triggered re-evaluation of the patient’s leiomyosarcoma.", + "CT imaging showed multifocal progression.", + "Second-line chemotherapy with trabectedin was commenced.", + "Systemic anti-cancer therapy was associated with mild improvement in dermatomyositis symptoms." + ], + "summary": "A 43-year-old female diagnosed with metastatic leiomyosarcoma of unknown primary presented with a mild rash in sun-exposed areas of her face and upper chest, with no other neuromuscular symptoms. This rash resolved with systemic treatment with doxorubicin for metastatic leiomyosarcoma. Imaging assessment confirmed overall stable disease after chemotherapy completion. She presented acutely 2 months later with new onset rash in a shawl-like distribution, periorbital oedema and proximal muscle weakness. Based on the characteristic cutaneous signs and symmetrical proximal muscle weakness, abnormal electromyography and raised skeletal muscle enzymes with a positive anti-transcription intermediary factor-1 gamma antibody result, a diagnosis of paraneoplastic dermatomyositis was made. Re-evaluation of her metastatic leiomyosarcoma revealed disease progression. Second-line chemotherapy was commenced once the dermatomyositis was controlled on steroid therapy. Systemic anti-cancer therapy was again associated with mild improvement in dermatomyositis symptoms.", + "summary_subclaims": [ + "The patient is a 43-year-old female.", + "She was diagnosed with metastatic leiomyosarcoma of unknown primary.", + "She had a mild rash in sun-exposed areas of her face and upper chest.", + "She had no other neuromuscular symptoms.", + "The rash resolved with systemic treatment with doxorubicin.", + "Imaging assessment confirmed overall stable disease after chemotherapy completion.", + "She presented 2 months later with new onset rash in a shawl-like distribution.", + "She had periorbital oedema.", + "She had proximal muscle weakness.", + "The diagnosis was based on characteristic cutaneous signs.", + "The diagnosis was based on symmetrical proximal muscle weakness.", + "The diagnosis was based on abnormal electromyography.", + "The diagnosis was based on raised skeletal muscle enzymes.", + "The diagnosis was based on a positive anti-transcription intermediary factor-1 gamma antibody result.", + "A diagnosis of paraneoplastic dermatomyositis was made.", + "Re-evaluation revealed disease progression of her metastatic leiomyosarcoma.", + "Second-line chemotherapy was commenced once the dermatomyositis was controlled on steroid therapy.", + "Systemic anti-cancer therapy was associated with mild improvement in dermatomyositis symptoms." + ] + }, + { + "id": "multiclinsum_test_3022_en.txt", + "fulltext": "The boy is a 10-year-old indigenous boy of the Kichwa people, born and living in the community of Kuchapamba (0°03’20.1” N, 76°58’29.5” W) in the parish of Santa Cecilia, in the canton of Lago Agrio, in the province of Sucumbíos, in the north of the Ecuadorian Amazon. The boy was referred from the Marco Vinicio Iza General Hospital, located in Nueva Loja (35.4 km from Kuchapamba), for respiratory symptoms such as cough and rusty expectoration and sometimes frank haemoptysis, which had been present for four years. His father reported that he occasionally had a fever and had been hospitalized three times; the presumptive diagnoses were pulmonary tuberculosis and pneumonia. The paternal grandfather died of pulmonary tuberculosis. However, all the patient’s sputum examinations were negative for Mycobacterium tuberculosis. During the last hospitalization, a chest tube was placed to drain the pleural effusion. Given the recurrence and persistence of the aforementioned symptoms, and in the absence of an etiological diagnosis, the patient was referred to the Baca Ortiz Paediatric Hospital in Quito (located in the Andean region, 293 km from Nueva Loja), to investigate the cause of the pulmonary symptoms. The father stated that the family diet included the consumption of freshwater crabs collected from the nearby creeks. They also eat fish, molluscs and meat from wild animals such as wild boars and guanta (Cuniculus spp.), among others.\n\nThe patient presented to the hospital admission examination with a temperature of 36°C, blood pressure of 115/76 mmHg, heart rate of 60 beats per minute, respiratory rate of 24 breaths per minute, weight of 26.8 kg, height of 126 cm, body mass index of 16.9 kg/m2, conscious, oriented in space, time and person, Glasgow Coma Scale of 15/15, no neurological focal signs, no palpable adenopathies, symmetric chest with preserved expansion capacity and decreased murmurs in the left lung base, no over-additive noises or respiratory distress, other physical findings were normal, and the patient expectorated copious rust-coloured sputum with streaks of blood, especially in the morning. This sputum was collected for microscopic examination for the presence of eggs of Paragonimus spp., M. tuberculosis bacilli and yeast. The haematological profile showed 6.1 x 103 leukocytes/μl (reference range: 4.4 - 11.0 x 103 cells/μl); 5.0 x 103 neutrophils/μl (2.5 - 7.5); 3.1 x 103 lymphocytes/μl (3.0 - 9.5); and 2.24 x 103 eosinophils/μl (1.0 - 1.5); haemoglobin of 9.7 g/dl (9.5 - 13.0); haematocrit of 29.6% (30 - 44%); and 306,000 platelets/μl (150,000 - 450,000). In addition, the results included: glucose of 102 mg/dl (100 - 180); urea of 6.8 mg/dl (5 - 18); creatinine of 0.17 mg/dl (0.3 - 0.7); glutamic oxaloacetic transaminase of 25.6 U/L (0 - 37); glutamic pyruvic transaminase of 28.6 U/L (> 60); gamma glutamyl transferase of 22 U/L (11 - 50); total bilirubin of 0.10 mg/dl (1.0); direct bilirubin of 0.04 mg/dl (0.3); alkaline phosphatase of 179 U/L (up to 350); lactate dehydrogenase of 203 U/L (170 - 580); total protein of 4.5 g/dl (4.4 - 5.4); albumin of 6.88 g/dl (6.2 - 8.0); and C-reactive protein of 1.33 mg/L (up to 10). The stool examination did not reveal parasitic cysts or eggs.\n\nIn the microscopic study of fresh sputum (without staining), abundant eggs, operculated and ovoid, indicative of Paragonimus spp. were observed. With the staining of Ziehl-Neelsen and acid-fast staining, no bacilli or fungal spores were observed. In the axial computed tomography of the thorax, simple and with contrast, a round lesion of 22 x 20 x 33 mm and a volume of approximately 8 ml with a hydroaereous level and gas foci in the anterior part, as well as consolidated areas around this lesion, were observed. In the left basal field, a patterned glass-milled image was visualized. After the parasitological diagnosis of pulmonary paragonimiasis was made, the sending of praziquantel or triclabendazole to the Ministry of Public Health of Ecuador was requested, and they responded that they did not have either of the two drugs. Triclabendazole was obtained in 250 mg tablets of Egaten® (Novartis) through the non-governmental organization “Centro de Epidemiología Comunitaria y Medicina Tropical”, in Esmeraldas, and a single daily dose of 10 mg/kg was administered orally for two days. After five days of hospitalization, the pulmonary symptoms disappeared. The patient did not present adverse or secondary effects, so he was discharged.In the last control, carried out one year after finishing the treatment, the father reported that the patient had presented sporadic cough without rusty expectoration. The patient underwent a physical examination whose findings were normal, and the microscopy of sputum for eggs of Paragonimus spp. and bacilli of M. tuberculosis was negative.\n", + "fulltext_subclaims": [ + "The boy is a 10-year-old indigenous boy of the Kichwa people.", + "The boy was referred from the Marco Vinicio Iza General Hospital.", + "The boy had respiratory symptoms such as cough and rusty expectoration.", + "The boy had symptoms for four years.", + "The boy had been hospitalized three times.", + "The presumptive diagnoses were pulmonary tuberculosis and pneumonia.", + "The paternal grandfather died of pulmonary tuberculosis.", + "All the patient’s sputum examinations were negative for Mycobacterium tuberculosis.", + "A chest tube was placed to drain the pleural effusion.", + "The patient was referred to the Baca Ortiz Paediatric Hospital in Quito.", + "The family diet included the consumption of freshwater crabs.", + "The patient expectorated copious rust-coloured sputum with streaks of blood.", + "The sputum was collected for microscopic examination for the presence of eggs of Paragonimus spp., M. tuberculosis bacilli and yeast.", + "The haematological profile showed 2.24 x 103 eosinophils/μl.", + "The stool examination did not reveal parasitic cysts or eggs.", + "In the microscopic study of fresh sputum, abundant eggs, operculated and ovoid, indicative of Paragonimus spp. were observed.", + "In the axial computed tomography of the thorax, a round lesion of 22 x 20 x 33 mm with a hydroaereous level and gas foci was observed.", + "In the left basal field, a patterned glass-milled image was visualized.", + "The sending of praziquantel or triclabendazole to the Ministry of Public Health of Ecuador was requested.", + "The Ministry of Public Health of Ecuador responded that they did not have either of the two drugs.", + "Triclabendazole was obtained in 250 mg tablets of Egaten® (Novartis).", + "A single daily dose of 10 mg/kg was administered orally for two days.", + "After five days of hospitalization, the pulmonary symptoms disappeared.", + "The patient did not present adverse or secondary effects.", + "In the last control, carried out one year after finishing the treatment, the father reported that the patient had presented sporadic cough without rusty expectoration.", + "The microscopy of sputum for eggs of Paragonimus spp. and bacilli of M. tuberculosis was negative." + ], + "summary": "A 10-year-old Kichwa boy from a rural community in the Amazon region was diagnosed at the Pediatric Hospital of Quito. The boy had been coughing and expectorating rusty sputum for four years, with a history of eating crabs. Computed tomography showed changes in the pulmonary parenchyma suggestive of pulmonary paragonimiasis. The diagnosis was confirmed by microscopic observation of operculated eggs of Paragonimus spp. in the sputum. Triclabendazole was administered for two days and subsequent controls showed negative results in the sputum.\n", + "summary_subclaims": [ + "The patient is a 10-year-old Kichwa boy.", + "The boy is from a rural community in the Amazon region.", + "The boy had been coughing for four years.", + "The boy had been expectorating rusty sputum for four years.", + "Computed tomography showed changes in the pulmonary parenchyma.", + "The changes in the pulmonary parenchyma were suggestive of pulmonary paragonimiasis.", + "The diagnosis was confirmed by microscopic observation of operculated eggs of Paragonimus spp. in the sputum.", + "Triclabendazole was administered for two days.", + "Subsequent controls showed negative results in the sputum." + ] + }, + { + "id": "multiclinsum_test_3362_en.txt", + "fulltext": "An 82-year-old patient was referred to our clinical immunology department – internal medicine for advice regarding a possible systemic disease. Her main medical history included a Horton disease diagnosed in 2006, for which she received long-term corticosteroid therapy, which was permanently discontinued in 2021, and a pancreatitis of undetermined etiology in 2011.\nThe current story began in 2021, with the incidental discovery of multiple hepatic nodules that led to a first liver biopsy in a peripheral hospital. The pathological examination was in favour of ischaemic necrosis lesions of undetermined origin. A few days after the biopsy, the patient presented hepatic cytolysis at 20 times the normal, without cholestasis, with a spontaneous and rapidly favourable evolution, but also with intense pruritus, persisting after several weeks. The diagnosis of prurigo nodularis was made by dermatologists. Dupilumab treatment was then initiated in this indication.\nThe patient was re-admitted in July 2022 due to the discovery of hyponatraemia on a follow-up assessment. The abdominal scan showed the persistence of hepatic nodules, motivating a second liver biopsy whose results confirmed an aspect of ischaemic necrosis, as well as a few contributing factors. The thoraco-abdomino-pelvic scan showed a lower right lobar pulmonary image evoking a pulmonary infarction in the first place, as well as a calcifying chronic pancreatitis. The Pet-scanner (18F-FDG) found a moderate hypermetabolism of the pulmonary lesion, leading to the realization of a biopsy in September 2022, showing chronic fibro-inflammatory changes with epithelioid and gigantocellular granulomas very focally necrosing. Bronchoscopy was without particularity and all infectious samples and especially mycobacterial cultures were negative. A tuberculosis was however evoked in view of the whole picture, and a test antituberculous treatment was started at the end of the year 2022, quickly complicated by a cutaneous reaction with pancreatitis and medicinal hepatitis motivating the cessation of treatment.\nShe was referred to us in this context for a diagnostic and therapeutic opinion. She was receiving treatment with perindopril, bisoprolol, levothyrox, magnesium, oral iron, and dupilumab (300 mg subcutaneously every two weeks) at the time of the consultation. Her main complaints were persistent asthenia and the reappearance of severe pruritus for several months with dupilumab. She remained very active, however, with estimated walking distance of 10 kilometres per day. She had gained weight since the last hospital admission. She did not have fever or night sweats. The clinical examination was without notable anomalies.\nBiologically, the NFS was unremarkable, CRP negative. Renal function and liver profile were normal, no electrophoresis peak, no hypo- or hypergammaglobulinemia. IgG4 was elevated at 2.21 g/L (N < 1.03 g/L). Autoimmune profile including antinuclear antibodies and ANCA was negative. There was no biological argument for granulomatosis (low ACE, 1.25-OH vitamin D in the norm). Quantiferon was negative. There was no significant proteinuria.\nFollowing the consultation, the diagnosis of tuberculosis was ruled out by the panel. A thoraco-abdomino-pelvic control scan was performed, revealing the presence of irregular and retractable lower right lobar alveolar condensation of 35 mm. In the abdominal level, there was a general stability of all known hypodens liver nodules. A liver MRI was performed as a complement, without additional diagnostic contribution, including after a specialised re-reading of all previous imaging.\n\nIn the case of an IgG4-associated disease, a re-read of the biopsy pieces was also requested, with additional IgG4 marking. The re-read of the pulmonary biopsy confirmed a chronic granulomatous, epithelioid and gigantic cellular inflammation, which was focally necrotic. The re-read of the hepatic biopsies was in favour of foci of non-tumour necrosis with inflammatory fibrosclerous shell, rich in IgG4 plasma cells, with an IgG4/IgG ratio > 40. However, the overall aspect was not in favour of an IgG4-associated disease, due to the absence of a storiform fibrosis or obliterative phlebitis, and the non-classical presence of a granulomatous epithelioid inflammation in the course of this disease.\nThe patient was re-admitted to hospital to discuss a new pulmonary biopsy, especially for the purpose of microbiological documentation, in order to exclude a tuberculosis with certainty in the absence of an alternative diagnosis. During the hospital stay, a complete infectious assessment was proposed. Finally, echinococcosis serology was positive in Western blot with a single band at 7 kDa, not allowing a species diagnosis (ELISA Em2+ and Em18 negative). The performance of molecular biology examinations was not possible at that time due to a failure to preserve the biopsy samples. In the case of an alveolar echinococcosis, treatment with albendazole was introduced in March 2023 in consultation with the infectiologists, and treatment with dupilumab was stopped.\nDuring follow-up, the patient developed a hepatic intolerance to albendazole treatment, then to mebendazole introduced in August 2023 (resolutive cytolysis at the end of treatment), as well as a hyper-eosinophilia. A control scan carried out in January 2024 showing an increase in size of the hepatic lesions, a new hepatic biopsy was proposed. The histology showed essentially a chronic non-specific inflammation, but the PCR E. multilocularis was positive, allowing the diagnosis of alveolar echinococcosis to be confirmed definitively.\n", + "fulltext_subclaims": [ + "The patient is an 82-year-old woman.", + "She was referred to the clinical immunology department – internal medicine.", + "Her main medical history included a Horton disease diagnosed in 2006.", + "She received long-term corticosteroid therapy for Horton disease.", + "Corticosteroid therapy was permanently discontinued in 2021.", + "She had a pancreatitis of undetermined etiology in 2011.", + "In 2021, multiple hepatic nodules were incidentally discovered.", + "A first liver biopsy was performed in a peripheral hospital.", + "The pathological examination was in favour of ischaemic necrosis lesions of undetermined origin.", + "A few days after the biopsy, the patient presented hepatic cytolysis at 20 times the normal.", + "There was no cholestasis.", + "The evolution of the hepatic cytolysis was spontaneous and rapidly favourable.", + "The patient had intense pruritus persisting after several weeks.", + "The diagnosis of prurigo nodularis was made by dermatologists.", + "Dupilumab treatment was initiated in this indication.", + "In July 2022, the patient was re-admitted due to the discovery of hyponatraemia.", + "An abdominal scan showed the persistence of hepatic nodules.", + "A second liver biopsy was performed.", + "The results of the second liver biopsy confirmed an aspect of ischaemic necrosis.", + "The thoraco-abdomino-pelvic scan showed a lower right lobar pulmonary image evoking a pulmonary infarction.", + "The scan also showed calcifying chronic pancreatitis.", + "The Pet-scanner (18F-FDG) found a moderate hypermetabolism of the pulmonary lesion.", + "A biopsy of the pulmonary lesion was performed in September 2022.", + "The biopsy showed chronic fibro-inflammatory changes with epithelioid and gigantocellular granulomas very focally necrosing.", + "Bronchoscopy was without particularity.", + "All infectious samples, especially mycobacterial cultures, were negative.", + "A tuberculosis was evoked in view of the whole picture.", + "A test antituberculous treatment was started at the end of the year 2022.", + "The antituberculous treatment was quickly complicated by a cutaneous reaction with pancreatitis.", + "The antituberculous treatment was also complicated by medicinal hepatitis.", + "The antituberculous treatment was stopped.", + "The patient was referred for a diagnostic and therapeutic opinion.", + "She was receiving treatment with perindopril, bisoprolol, levothyrox, magnesium, oral iron, and dupilumab.", + "Her main complaints were persistent asthenia and the reappearance of severe pruritus for several months with dupilumab.", + "She remained very active, with an estimated walking distance of 10 kilometres per day.", + "She had gained weight since the last hospital admission.", + "She did not have fever or night sweats.", + "The clinical examination was without notable anomalies.", + "The NFS was unremarkable.", + "CRP was negative.", + "Renal function and liver profile were normal.", + "There was no hypo- or hypergammaglobulinemia.", + "IgG4 was elevated at 2.21 g/L.", + "Autoimmune profile including antinuclear antibodies and ANCA was negative.", + "There was no biological argument for granulomatosis.", + "Quantiferon was negative.", + "The diagnosis of tuberculosis was ruled out by the panel.", + "A thoraco-abdomino-pelvic control scan was performed.", + "The scan revealed the presence of irregular and retractable lower right lobar alveolar condensation of 35 mm.", + "There was a general stability of all known hypodens liver nodules.", + "A liver MRI was performed as a complement.", + "The liver MRI did not provide additional diagnostic contribution.", + "A re-read of the biopsy pieces was requested, with additional IgG4 marking.", + "The re-read of the pulmonary biopsy confirmed a chronic granulomatous, epithelioid and gigantic cellular inflammation, which was focally necrotic.", + "The re-read of the hepatic biopsies was in favour of foci of non-tumour necrosis with inflammatory fibrosclerous shell, rich in IgG4 plasma cells, with an IgG4/IgG ratio > 40.", + "The overall aspect was not in favour of an IgG4-associated disease.", + "The patient was re-admitted to hospital to discuss a new pulmonary biopsy.", + "A complete infectious assessment was proposed.", + "Echinococcosis serology was positive in Western blot with a single band at 7 kDa.", + "ELISA Em2+ and Em18 were negative.", + "Molecular biology examinations could not be performed due to a failure to preserve the biopsy samples.", + "In the case of an alveolar echinococcosis, treatment with albendazole was introduced in March 2023.", + "Treatment with dupilumab was stopped.", + "The patient developed a hepatic intolerance to albendazole treatment.", + "She also developed a hepatic intolerance to mebendazole introduced in August 2023.", + "A control scan carried out in January 2024 showed an increase in size of the hepatic lesions.", + "A new hepatic biopsy was proposed.", + "The histology showed essentially a chronic non-specific inflammation.", + "The PCR E. multilocularis was positive.", + "The diagnosis of alveolar echinococcosis was confirmed definitively." + ], + "summary": "We report the case of an 82-year-old patient who was immunosuppressed by prolonged corticosteroid therapy and dupilumab treatment. She was referred to our department for a diagnostic assessment of atypical liver and lung lesions, initially suspected of tuberculosis or IgG4-associated disease. The hypothesis of an alveolar echinococcosis with E. multilocularis could be raised on a set of arguments and then confirmed by molecular diagnosis. We discuss the role of dupilumab in the systemic evolution and atypical presentation of the disease, by the induction of a specific immunosuppression.\n", + "summary_subclaims": [ + "The patient was an 82-year-old woman.", + "The patient was immunosuppressed by prolonged corticosteroid therapy.", + "The patient was receiving dupilumab treatment.", + "The patient was referred for a diagnostic assessment of atypical liver and lung lesions.", + "The lesions were initially suspected to be tuberculosis.", + "The lesions were initially suspected to be IgG4-associated disease.", + "The hypothesis of alveolar echinococcosis with E. multilocularis could be raised.", + "The hypothesis was confirmed by molecular diagnosis.", + "The role of dupilumab in the systemic evolution and atypical presentation of the disease is discussed.", + "Dupilumab may induce specific immunosuppression." + ] + }, + { + "id": "multiclinsum_test_3286_en.txt", + "fulltext": "History of Presentation\nA 53-year-old man with a history of multiple previous percutaneous coronary intervention (PCI) treatments had an angina on effort with Canadian Cardiovascular Society class II. Coronary angiography (CAG) revealed 90% stenosis in the stent implanted 4 years before, and he was admitted for revascularization.\n\nPast Medical History\nFour years before, the patient underwent catheter ablation for symptomatic paroxysmal atrial fibrillation. At the same time, he was also aware of angina on effort, and CAG performed during the ablation procedure showed 90% stenosis with severe calcification in the proximal segment of the left anterior descending artery (LAD). He then underwent PCI. Despite extensive preparation with rotational atherectomy of 1.25-mm burr and predilatation by 2.5-mm cutting balloon, a 2.75- × 20-mm drug-eluting stent was insufficiently expanded even after postdilatation with a 2.75-mm noncompliant balloon. Two years before, the patient complained of angina symptoms and CAG showed in-stent restenosis (ISR) of 90% stenosis. We performed revascularization, but high-pressure dilation of 12 atm with a 2.75-mm cutting balloon and 25 atm with a 3.0-mm noncompliant balloon did not provide sufficient dilation eventually.\n\nDifferential Diagnosis\nOther causes of chest pain were ruled out. Chest radiography did not show any signs of heart failure or respiratory disease. Despite a history of catheter ablation for paroxysmal atrial fibrillation, he had been in sinus rhythm and there was no evidence of tachycardia event. His chest pain was similar to the symptoms which he felt at previous PCIs.\n\nInvestigations\nThe 12-lead electrocardiogram showed sinus rhythm and no significant ST-segment changes, and transthoracic echocardiogram showed no significant asynergy and preserved left ventricular systolic function with an ejection fraction of 74%. Moreover, myocardial perfusion single photon emission computed tomography implied anterior ischemia and CAG showed 90% ISR with severe calcification in the proximal LAD.\n\nManagement\nVia a right distal radial artery approach with a 6-F Judkins Left 4.0 guide catheter (Mach 1; Boston Scientific) a guidewire (SION blue; Asahi Intecc) was crossed into the distal LAD successfully. Supported with a guide extension catheter (GUIDEPLUS, NIPRO), optical coherence tomography (OCT) (Dragonfly OPTIS, Abbott Vascular) examination was performed and we found circumferential thick calcification outside of the stent. Even though 3.0-mm scoring balloon inflation with up to 24 atm, the lesion proved resistant to expansion. Then, we exchanged to 7-F SPB 3.5 guide catheter (Hyperion, Asahi Intecc) to enforce the backup power and 1.75-mm burr rotational atherectomy was performed. Even after rotational atherectomy, high-pressure dilatation with a 3.0-mm scoring balloon up to 24 atm again did not provide adequate stent expansion. Therefore, we decided on a strategy of treatment by intravascular lithotripsy (IVL). A lithotripsy balloon 3.0 × 12 mm (Shockwave Medical) was positioned across the underexpanded segment of the stent. The balloon was inflated to 4 atm and 10 shockwave pulses were delivered at a rate of 1 pulse per second, following which the balloon was inflated further to 6 atm for 5 to 10 seconds, which was repeated multiple times, and then excellent dilation was seen at the second 10 pulses. Additional 40 pulses were delivered eventually, and the stent appeared to have expanded fully on repeat angiography and OCT observation. Finally, the lesion was dilated with a 3.0-mm drug-coated balloon (SeQuent Please NEO, NIPRO) up to 6 atm. We confirmed sufficient stent and lumen expansion on angiogram and OCT with the final lumen area of 7.08 mm2 at underexpanded stent segment. Therefore, we finished the PCI procedure without any complications, and the patient was discharged 2 days after PCI.\n\nFollow-Up\nDuring the outpatient clinic follow-up, there were no clinical events and the patient did not complain of angina symptoms. Seven months later, follow-up CAG accompanied with OCT and coronary angioscopy (CAS) imaging were conducted. On CAG, there was no stent restenosis with patent stent. OCT revealed homogeneous neointimal coverage of stent struts with sustained acute lumen gain and no evidence of stent recoil or ISR. Notably, post-PCI fractured thick calcium outside the stent at the index PCI had disappeared. In addition, CAS showed the stable white color neointima and a few stent struts with dull light reflection", + "fulltext_subclaims": [ + "The patient is a 53-year-old man.", + "He has a history of multiple previous percutaneous coronary intervention (PCI) treatments.", + "He had angina on effort with Canadian Cardiovascular Society class II.", + "Coronary angiography (CAG) revealed 90% stenosis in the stent implanted 4 years before.", + "He was admitted for revascularization.", + "Four years before, the patient underwent catheter ablation for symptomatic paroxysmal atrial fibrillation.", + "At the same time, he was aware of angina on effort.", + "CAG performed during the ablation procedure showed 90% stenosis with severe calcification in the proximal segment of the left anterior descending artery (LAD).", + "He then underwent PCI.", + "Despite extensive preparation with rotational atherectomy of 1.25-mm burr and predilatation by 2.5-mm cutting balloon, a 2.75- × 20-mm drug-eluting stent was insufficiently expanded even after postdilatation with a 2.75-mm noncompliant balloon.", + "Two years before, the patient complained of angina symptoms.", + "CAG showed in-stent restenosis (ISR) of 90% stenosis.", + "We performed revascularization.", + "High-pressure dilation of 12 atm with a 2.75-mm cutting balloon and 25 atm with a 3.0-mm noncompliant balloon did not provide sufficient dilation eventually.", + "Other causes of chest pain were ruled out.", + "Chest radiography did not show any signs of heart failure or respiratory disease.", + "Despite a history of catheter ablation for paroxysmal atrial fibrillation, he had been in sinus rhythm.", + "There was no evidence of tachycardia event.", + "His chest pain was similar to the symptoms which he felt at previous PCIs.", + "The 12-lead electrocardiogram showed sinus rhythm and no significant ST-segment changes.", + "Transthoracic echocardiogram showed no significant asynergy and preserved left ventricular systolic function with an ejection fraction of 74%.", + "Myocardial perfusion single photon emission computed tomography implied anterior ischemia.", + "CAG showed 90% ISR with severe calcification in the proximal LAD.", + "Via a right distal radial artery approach with a 6-F Judkins Left 4.0 guide catheter, a guidewire was crossed into the distal LAD successfully.", + "Supported with a guide extension catheter, optical coherence tomography (OCT) examination was performed.", + "We found circumferential thick calcification outside of the stent.", + "Even though 3.0-mm scoring balloon inflation with up to 24 atm, the lesion proved resistant to expansion.", + "We exchanged to 7-F SPB 3.5 guide catheter to enforce the backup power.", + "1.75-mm burr rotational atherectomy was performed.", + "Even after rotational atherectomy, high-pressure dilatation with a 3.0-mm scoring balloon up to 24 atm again did not provide adequate stent expansion.", + "We decided on a strategy of treatment by intravascular lithotripsy (IVL).", + "A lithotripsy balloon 3.0 × 12 mm was positioned across the underexpanded segment of the stent.", + "The balloon was inflated to 4 atm and 10 shockwave pulses were delivered at a rate of 1 pulse per second.", + "Following which the balloon was inflated further to 6 atm for 5 to 10 seconds, which was repeated multiple times.", + "Excellent dilation was seen at the second 10 pulses.", + "Additional 40 pulses were delivered eventually.", + "The stent appeared to have expanded fully on repeat angiography and OCT observation.", + "Finally, the lesion was dilated with a 3.0-mm drug-coated balloon up to 6 atm.", + "We confirmed sufficient stent and lumen expansion on angiogram and OCT with the final lumen area of 7.08 mm2 at underexpanded stent segment.", + "We finished the PCI procedure without any complications.", + "The patient was discharged 2 days after PCI.", + "During the outpatient clinic follow-up, there were no clinical events.", + "The patient did not complain of angina symptoms.", + "Seven months later, follow-up CAG accompanied with OCT and coronary angioscopy imaging were conducted.", + "On CAG, there was no stent restenosis with patent stent.", + "OCT revealed homogeneous neointimal coverage of stent struts with sustained acute lumen gain.", + "There was no evidence of stent recoil or ISR.", + "Post-PCI fractured thick calcium outside the stent at the index PCI had disappeared.", + "CAS showed the stable white color neointima and a few stent struts with dull light reflection." + ], + "summary": "A 53-year-old man with stable angina underwent drug-eluting stent implantation in the left anterior descending artery lesion with severe calcification 4 years before and an underexpansion remained. Despite high-pressure balloon dilatations with multiple sessions, adequate lumen area could not be obtained. However, we performed revascularization with IVL and excellent stent expansion was achieved. Seven months later, follow-up coronary angiography with optical coherence tomography and coronary angioscopy revealed sustained acute lumen gain with no evidence of stent recoil or ISR.", + "summary_subclaims": [ + "The patient is a 53-year-old man.", + "He has stable angina.", + "He underwent drug-eluting stent implantation in the left anterior descending artery lesion.", + "The lesion had severe calcification.", + "The stent implantation was 4 years before.", + "An underexpansion remained.", + "High-pressure balloon dilatations with multiple sessions were performed.", + "Adequate lumen area could not be obtained.", + "We performed revascularization with IVL.", + "Excellent stent expansion was achieved.", + "Seven months later, follow-up coronary angiography was performed.", + "Optical coherence tomography was used.", + "Coronary angioscopy was used.", + "Sustained acute lumen gain was revealed.", + "There was no evidence of stent recoil.", + "There was no evidence of ISR." + ] + }, + { + "id": "multiclinsum_test_3145_en.txt", + "fulltext": "A 38-year-old man was referred to the International Hospital of Colombia (Bucaramanga) for treatment-resistant focal epilepsy associated with cognitive deficits.\n\nThe patient was the only child of the third pregnancy, born by uncomplicated vaginal delivery, with normal neurodevelopment until the age of 10 years and no history of neuroinfections, major surgeries or haematological disorders. He reported a head injury at the age of 10 years, after which he developed apparent cognitive impairment with poor school performance. One year after the injury, he had his first seizure. The seizures consisted of clonic movements in the left hemicorper, with more involvement of the upper limb and sometimes accompanied by headaches. On the EEG, interictal and ictal activity was observed in the right fronto-central region.\n\nLaboratory studies to exclude infectious and metabolic disorders were performed and were negative. A simple computed tomography of the skull was performed and showed agenesis of the pellucidum and dysgenesis of the corpus callosum.\n\nSubsequently, a brain MRI was performed with the protocol for epilepsy, which showed several clinically relevant findings, including confirmation of agenesis of the pellucidum, and suggestive of polymicrogyria, such as abnormal thickening and irregularity in several areas of the cerebral cortex, particularly in the frontal lobes and in both perisylvian regions. In addition, heterotopic gray matter was identified in the frontal lobes, most notably in the right, where two bands of abnormal, thickened gray matter were identified extending from the cortex to the lateral ventricle wall.\n\nAnother band of heterotopic grey matter was identified in the left fronto-insular region, parallel to the lateral ventricle. There was also a supratentorial ventriculomegaly and, although the corpus callosum was present, its apex or rostrum had an atypical appearance. The chiasm and optic nerves were hypoplastic.\n\nIt should be noted that the EEG findings correlated with areas of polymyocryria and cortical heterotopia in the right cerebral hemisphere.\n\nAlthough there was a history of head trauma, in the absence of findings such as areas of gliosis or bleeding, this trauma was considered to be mild, with no structural sequelae evident in the two studies obtained. Therefore, this history was most likely not directly related to the patient's clinical manifestations.\n\nOnce the diagnosis was confirmed, in the initial control of the symptoms, and given the presence of bilateral lesions that compromised some critical areas, it was decided to provide medical treatment with a new anticonvulsive medication scheme and to carry out periodic monitoring in the institution.\n", + "fulltext_subclaims": [ + "The patient is a 38-year-old man.", + "He was referred to the International Hospital of Colombia (Bucaramanga) for treatment-resistant focal epilepsy.", + "The epilepsy is associated with cognitive deficits.", + "He was the only child of the third pregnancy.", + "He was born by uncomplicated vaginal delivery.", + "Neurodevelopment was normal until the age of 10 years.", + "He had no history of neuroinfections.", + "He had no history of major surgeries.", + "He had no history of haematological disorders.", + "He reported a head injury at the age of 10 years.", + "After the head injury, he developed apparent cognitive impairment.", + "He had poor school performance after the head injury.", + "One year after the injury, he had his first seizure.", + "The seizures consisted of clonic movements in the left hemicorper.", + "The seizures had more involvement of the upper limb.", + "The seizures were sometimes accompanied by headaches.", + "On the EEG, interictal and ictal activity was observed in the right fronto-central region.", + "Laboratory studies to exclude infectious and metabolic disorders were performed.", + "The laboratory studies were negative.", + "A simple computed tomography of the skull was performed.", + "The CT showed agenesis of the pellucidum.", + "The CT showed dysgenesis of the corpus callosum.", + "A brain MRI was performed with the protocol for epilepsy.", + "The MRI showed confirmation of agenesis of the pellucidum.", + "The MRI showed findings suggestive of polymicrogyria.", + "The MRI showed abnormal thickening and irregularity in several areas of the cerebral cortex.", + "The abnormal thickening and irregularity were particularly in the frontal lobes.", + "The abnormal thickening and irregularity were particularly in both perisylvian regions.", + "Heterotopic gray matter was identified in the frontal lobes.", + "The heterotopic gray matter was most notable in the right frontal lobe.", + "Two bands of abnormal, thickened gray matter were identified in the right frontal lobe.", + "The bands extended from the cortex to the lateral ventricle wall.", + "Another band of heterotopic grey matter was identified in the left fronto-insular region.", + "The band in the left fronto-insular region was parallel to the lateral ventricle.", + "There was supratentorial ventriculomegaly.", + "The corpus callosum was present.", + "The corpus callosum's apex or rostrum had an atypical appearance.", + "The chiasm and optic nerves were hypoplastic.", + "The EEG findings correlated with areas of polymicrogyria and cortical heterotopia in the right cerebral hemisphere.", + "There was a history of head trauma.", + "In the absence of findings such as areas of gliosis or bleeding, the trauma was considered to be mild.", + "The trauma was considered to have no structural sequelae evident in the two studies obtained.", + "The history of head trauma was most likely not directly related to the patient's clinical manifestations.", + "Once the diagnosis was confirmed, medical treatment with a new anticonvulsive medication scheme was decided.", + "Periodic monitoring in the institution was decided." + ], + "summary": "A 35-year-old man with a history of childhood head trauma and a history of treatment-resistant focal epilepsy associated with cognitive deficits presents. On initial evaluation, a computed tomography scan of the skull showed agenesis of the pellucidum and dysgenesis of the corpus callosum. A brain MRI confirmed the agenesis of the pellucidum and also revealed irregularity and abnormal thickening of the cerebral cortex in the frontal lobes and perisylvian region, and heterotopic gray matter in the frontal lobes and left frontoinsular region, mild supratentorial ventriculomegaly, atypical appearance of the rostrum of the corpus callosum, and hypoplasia of the chiasm and optic nerves.\n", + "summary_subclaims": [ + "The patient is a 35-year-old man.", + "The patient has a history of childhood head trauma.", + "The patient has a history of treatment-resistant focal epilepsy.", + "The patient has cognitive deficits.", + "A computed tomography scan of the skull showed agenesis of the pellucidum.", + "A computed tomography scan of the skull showed dysgenesis of the corpus callosum.", + "A brain MRI confirmed the agenesis of the pellucidum.", + "A brain MRI revealed irregularity and abnormal thickening of the cerebral cortex in the frontal lobes.", + "A brain MRI revealed irregularity and abnormal thickening of the cerebral cortex in the perisylvian region.", + "A brain MRI revealed heterotopic gray matter in the frontal lobes.", + "A brain MRI revealed heterotopic gray matter in the left frontoinsular region.", + "A brain MRI showed mild supratentorial ventriculomegaly.", + "A brain MRI showed an atypical appearance of the rostrum of the corpus callosum.", + "A brain MRI showed hypoplasia of the chiasm.", + "A brain MRI showed hypoplasia of the optic nerves." + ] + }, + { + "id": "multiclinsum_test_2136_en.txt", + "fulltext": "A 31-year-old woman with complaints of mild dyspnoea on exertion over the last several years was referred to our institution for liver dysfunction and cirrhosis. She had a significant medical history of congenital atrial stand-still and atrial septal defect (ASD) at birth. She had undergone no interventions immediately after the birth and ASD patch closure and EP implantation at the age of 6 years. Her generator was exchanged at the ages of 17 and 23 years. Although the EP generator was extracted and replaced by a transvenous endocardial pacemaker (ventricular sensing and pacing) at the age of 30 years, EP leads had been abandoned after the transvenous endocardial pacemaker implantation. The patient had no relevant family history.\nAt initial presentation, her blood pressure was 131/80 mmHg, pulse rate was 60 beats per minute (b.p.m.), and her oxygen saturation was 98% at rest. Physical examination was normal, save for mild peripheral oedema. An electrocardiogram showed a ventricular pacing rhythm with a heart rate of 60 b.p.m. Blood investigations revealed thrombocytopenia with a platelet count of 98 000/µL (reference range 158 000–348 000/µL); mild liver dysfunction; and an elevated B-type natriuretic peptide level of 41.9 pg/mL (reference range <18.4 pg/mL). Coagulation capacity was within the normal range. Antibody titres related to autoimmune disease, hepatitis viruses, and human immunodeficiency virus were negative. Tumour markers and interferon-gamma release assay results were negative. Chest radiography revealed bilateral enlargement of the pulmonary artery with cardiomegaly, EP leads with the loop placed on the anterior surface of the heart, and the endocardial pacemaker . Computed tomography (CT) scan of the thorax showed calcified EP leads on the anterior surface of the heart; CT scan of the abdomen revealed surface nodularity of the liver suggesting cirrhosis and mild ascites, with no evidence of spontaneous portosystemic shunts other than the splenorenal shunt . Transthoracic echocardiography demonstrated diffusely reduced left ventricular wall motion with an ejection fraction of 49%, bi-atrial enlargement, moderate mitral regurgitation due to left atrial enlargement, and dilatation of the inferior vena cava. There was no evidence of ventricular septal diastolic shudder, respiration-related ventricular septal shift, intracardiac shunt including residual ASD, or pericardial effusion. On pulsed-wave tissue Doppler imaging, the lateral and medial velocities of the mitral annulus in early diastole (e′) were 16.5 cm/s and 9.5 cm/s, respectively. The tricuspid annular plane systolic excursion was 10.9 mm and the tricuspid annular velocity in systole (s′) was 6.6 cm/s. Coronary angiography revealed no evidence of coronary stenosis. Right heart catheterization (RHC) showed a right atrial pressure of 14 mmHg, pulmonary artery pressure of 36/16 mmHg, mean pulmonary artery pressure of 24 mmHg, pulmonary capillary wedge pressure of 18 mmHg, cardiac index of 2.48 L/min/m2, pulmonary artery saturation of 78%, and waveforms similar to those of constrictive pericarditis (CP) . These results suggested that she had developed cardiac strangulation by the EP leads with haemodynamics similar to those of CP, leading to congestive hepatopathy with cirrhosis. Upon arriving at this diagnosis, complete EP lead removal and mitral valve repair were successfully performed .\nAfter surgical removal, her dyspnoea on exertion was improved. Further, RHC 1 year after surgery showed a right atrial pressure of 6 mmHg, pulmonary artery pressure of 19/12 mmHg, mean pulmonary artery pressure of 15 mmHg, pulmonary capillary wedge pressure of 13 mmHg, cardiac index of 3.46 L/min/m2, and pulmonary artery saturation of 80%. The waveforms of RHC after surgery also changed compared with those before surgery . The medication administered immediately after surgery included a beta-blocker, angiotensin-converting enzyme inhibitor, mineralocorticoid receptor antagonist, loop diuretic, and vitamin K antagonist. However, all medication has since been stopped because of pregnancy. The patient has shown no worsening of heart failure or other unanticipated events until the present time.", + "fulltext_subclaims": [ + "The patient is a 31-year-old woman.", + "She had a significant medical history of congenital atrial stand-still.", + "She had a significant medical history of atrial septal defect (ASD) at birth.", + "She had undergone no interventions immediately after the birth.", + "She had undergone ASD patch closure and EP implantation at the age of 6 years.", + "Her generator was exchanged at the ages of 17 and 23 years.", + "The EP generator was extracted and replaced by a transvenous endocardial pacemaker at the age of 30 years.", + "EP leads had been abandoned after the transvenous endocardial pacemaker implantation.", + "The patient had no relevant family history.", + "At initial presentation, her blood pressure was 131/80 mmHg.", + "Her oxygen saturation was 98% at rest.", + "An electrocardiogram showed a ventricular pacing rhythm with a heart rate of 60 b.p.m.", + "Blood investigations revealed thrombocytopenia with a platelet count of 98 000/µL.", + "Chest radiography revealed bilateral enlargement of the pulmonary artery.", + "Computed tomography (CT) scan of the thorax showed calcified EP leads on the anterior surface of the heart.", + "Transthoracic echocardiography demonstrated diffusely reduced left ventricular wall motion.", + "Right heart catheterization showed a right atrial pressure of 14 mmHg.", + "These results suggested that she had developed cardiac strangulation by the EP leads.", + "Complete EP lead removal and mitral valve repair were successfully performed.", + "After surgical removal, her dyspnoea on exertion was improved.", + "Right heart catheterization 1 year after surgery showed a right atrial pressure of 6 mmHg.", + "The medication administered immediately after surgery included a beta-blocker.", + "All medication has since been stopped because of pregnancy." + ], + "summary": "A 31-year-old woman with a history of atrial septal defect (ASD) patch closure and EP implantation for congenital atrial stand-still presented with dyspnoea on exertion. The blood investigation of the patient showed liver dysfunction, chest radiography showed pulmonary artery dilatation, and transthoracic echocardiography showed right chambers dysfunction. Right heart catheterization showed haemodynamics similar to those of constrictive pericarditis, eventually leading to the diagnosis of CS due to EP leads. The patient was successfully operated upon.", + "summary_subclaims": [ + "The patient is a 31-year-old woman.", + "She has a history of atrial septal defect (ASD) patch closure.", + "She has a history of EP implantation for congenital atrial stand-still.", + "She presented with dyspnoea on exertion.", + "The blood investigation showed liver dysfunction.", + "Chest radiography showed pulmonary artery dilatation.", + "Transthoracic echocardiography showed right chambers dysfunction.", + "Right heart catheterization showed haemodynamics similar to those of constrictive pericarditis.", + "The diagnosis was CS due to EP leads.", + "The patient was successfully operated upon." + ] + }, + { + "id": "multiclinsum_test_858_en.txt", + "fulltext": "A 72-year-old Japanese woman on medications for hypertension, obesity, and diabetes mellitus, was referred to our hospital with abnormal uterine bleeding. She was previously diagnosed with abnormal endometrial cytology at a previous clinic and visited our hospital for further examination and treatment. Endometrial biopsy revealed an adenocarcinoma (G2), while pelvic magnetic resonance imaging revealed a lesion mass of size 60 × 66 × 53 mm in the right side of the uterus , which was suspected to invade the serosal side. An enlarged lymph node measuring 18 mm was also found in the lymph node clusters in the right internal iliac artery and the obturator lymph node. Therefore, hysterectomy, bilateral adnexectomy, pelvic lymph node dissection, and para-aortic lymph node dissection were performed. A pathological examination using surgical specimen revealed endometrial serous carcinoma . Finally, she was diagnosed with stage III C2 endometrial cancer.\nOn the 6th postoperative day (POD), the patient developed abdominal bloating and nausea. Abdominal radiography revealed that the stomach and the intestine were markedly dilated with gas and air-fluid levels, indicating paralytic ileus . Thus, the patient was initiated on fasting and fluid replacement therapy, following which she recovered completely within 4 days. On the 27th POD, the patient received the first cycle of combination chemotherapy consisting of paclitaxel (175 mg/m2; 3-h infusion) and carboplatin (at a dose corresponding to an area under the curve [AUC] of 5 mg/mL/min).\nOn day 5 of chemotherapy, the patient developed a fever (38.6 °C), diarrhea, and fatigue. Her pulse rate, respiratory rate, and blood pressure were 120 beats/min, 20 breaths/min, and 88/52 mmHg, respectively. Blood examination revealed a white blood cell count, neutrophil count, and C-reactive protein (CRP) level of 270/μL, 40/μL, and 17.92 mg/dL, respectively, which were suggestive of the systemic inflammatory response syndrome including febrile neutropenia (FN) and sepsis. Therefore, an antibiotic therapy and granulocyte-colony stimulating factor therapy were initiated immediately. However, her condition worsened the next day. The body temperature, pulse rate, respiratory rate, blood pressure, white blood cell count, neutrophil count, and CRP level were 40.2 °C, 150 beats/min, 49 breaths/min, 63/42 mmHg, 150/μL, 0/μL, and 41.5 mg/dL, respectively.\nBecause she suffered from septic shock and DIC, she was shifted to the intensive care unit (ICU). Computed tomography (CT) of the abdomen and pelvis revealed remarkable intestinal dilation and thickening of the intestinal wall. Therefore, we considered enteritis as the origin of inflammation . Furthermore, we speculated that the patient’s condition was associated with toxicity due to bacterial translocation. However, no bacteria were detected in the blood and intestinal fluid. In addition to the treatment for septic shock and DIC, a long ileus tube was inserted into the stomach through the nasal cavity because she experienced a constant high-pressure feeling in the intestine and because we had to suction the extra air and fluid. Favorable outcomes were achieved, including reduced edema in the intestinal colon, improved circulation in the involved intestine, and correction of the intestinal kinking. Her condition gradually improved, and the neutrophil count and immune function improved from the 4th day of ICU admission. She was discharged alive and well from the ICU after 18 days . The patient’s clinical course is shown in Fig. . Written informed consent was obtained from the patient for participating in all procedures, and this work was approved by the Institutional Review Board of the Shimane University (IRB No-20200110-1).", + "fulltext_subclaims": [ + "The patient is a 72-year-old Japanese woman.", + "She was on medications for hypertension, obesity, and diabetes mellitus.", + "She was referred to the hospital with abnormal uterine bleeding.", + "She was previously diagnosed with abnormal endometrial cytology at a previous clinic.", + "Endometrial biopsy revealed an adenocarcinoma (G2).", + "Pelvic magnetic resonance imaging revealed a lesion mass of size 60 × 66 × 53 mm in the right side of the uterus.", + "The lesion was suspected to invade the serosal side.", + "An enlarged lymph node measuring 18 mm was found in the lymph node clusters in the right internal iliac artery.", + "An enlarged lymph node measuring 18 mm was found in the obturator lymph node.", + "Hysterectomy, bilateral adnexectomy, pelvic lymph node dissection, and para-aortic lymph node dissection were performed.", + "Pathological examination using surgical specimen revealed endometrial serous carcinoma.", + "She was diagnosed with stage III C2 endometrial cancer.", + "On the 6th postoperative day, the patient developed abdominal bloating and nausea.", + "Abdominal radiography revealed marked dilation of the stomach and intestine with gas and air-fluid levels.", + "The findings indicated paralytic ileus.", + "The patient was initiated on fasting and fluid replacement therapy.", + "She recovered completely within 4 days.", + "On the 27th postoperative day, the patient received the first cycle of combination chemotherapy.", + "The chemotherapy consisted of paclitaxel (175 mg/m2; 3-h infusion) and carboplatin (AUC 5 mg/mL/min).", + "On day 5 of chemotherapy, the patient developed a fever (38.6 °C), diarrhea, and fatigue.", + "Her white blood cell count was 270/μL.", + "Her neutrophil count was 40/μL.", + "Her C-reactive protein level was 17.92 mg/dL.", + "The findings were suggestive of systemic inflammatory response syndrome including febrile neutropenia and sepsis.", + "Antibiotic therapy and granulocyte-colony stimulating factor therapy were initiated.", + "Her condition worsened the next day.", + "Her body temperature was 40.2 °C.", + "Her white blood cell count was 150/μL.", + "Her neutrophil count was 0/μL.", + "Her C-reactive protein level was 41.5 mg/dL.", + "She was shifted to the intensive care unit because of septic shock and DIC.", + "Computed tomography revealed remarkable intestinal dilation and thickening of the intestinal wall.", + "We considered enteritis as the origin of inflammation.", + "We speculated that the patient’s condition was associated with toxicity due to bacterial translocation.", + "No bacteria were detected in the blood and intestinal fluid.", + "A long ileus tube was inserted into the stomach through the nasal cavity.", + "Favorable outcomes were achieved, including reduced edema in the intestinal colon.", + "Improved circulation in the involved intestine was achieved.", + "Intestinal kinking was corrected.", + "Her condition gradually improved.", + "The neutrophil count and immune function improved from the 4th day of ICU admission.", + "She was discharged alive and well from the ICU after 18 days.", + "Written informed consent was obtained from the patient.", + "This work was approved by the Institutional Review Board of the Shimane University (IRB No-20200110-1)." + ], + "summary": "We report the case of a 72-year-old woman with endometrial cancer who was undergoing treatment for hypertension, obesity and diabetes mellitus. The patient initially developed paralytic ileus on the 6th postoperative day (POD) after surgery for endometrial serous carcinoma. Complete recovery was achieved after 4 days of fasting and fluid replacement therapy. On the 27th POD, she received the first cycle of combination chemotherapy consisting of paclitaxel and carboplatin. On day 5 of chemotherapy, she developed the systemic inflammatory response syndrome including febrile neutropenia and sepsis. She then developed disseminated intravascular coagulation (DIC) and septic shock. The patient was subsequently moved to the intensive care unit (ICU). Despite initiating the standard treatment for septic shock and DIC, her overall status worsened. It was assumed that gut distention had led to bowel damage, subsequently leading to bacterial translocation. Thus, she developed NE with severe DIC and septic shock. We decided to reduce the intestinal pressure using an ileus tube to suction the additional air and fluid, even though doing so had a risk of worsening her general condition. The inflammatory reaction subsided, and her general condition improved. The patient recovered after 18 days in the ICU and was discharged alive.", + "summary_subclaims": [ + "The patient was a 72-year-old woman.", + "The patient had endometrial cancer.", + "The patient was undergoing treatment for hypertension.", + "The patient was undergoing treatment for obesity.", + "The patient was undergoing treatment for diabetes mellitus.", + "The patient developed paralytic ileus on the 6th postoperative day.", + "Complete recovery was achieved after 4 days of fasting and fluid replacement therapy.", + "On the 27th postoperative day, she received the first cycle of combination chemotherapy.", + "The chemotherapy consisted of paclitaxel and carboplatin.", + "On day 5 of chemotherapy, she developed the systemic inflammatory response syndrome.", + "The systemic inflammatory response syndrome included febrile neutropenia.", + "The systemic inflammatory response syndrome included sepsis.", + "She developed disseminated intravascular coagulation.", + "She developed septic shock.", + "The patient was moved to the intensive care unit.", + "Standard treatment for septic shock was initiated.", + "Standard treatment for DIC was initiated.", + "It was assumed that gut distention had led to bowel damage.", + "It was assumed that bowel damage had led to bacterial translocation.", + "She developed necrotizing enterocolitis.", + "A decision was made to reduce intestinal pressure using an ileus tube.", + "The inflammatory reaction subsided.", + "Her general condition improved.", + "The patient recovered after 18 days in the ICU.", + "The patient was discharged alive." + ] + }, + { + "id": "multiclinsum_test_2490_en.txt", + "fulltext": "A 46-year-old male with an incomplete tetraplegia (AIS B, neurological level C7), 5 years post injury consented to participate. The study was approved by the Ethics Committee of the Hospital District of Helsinki and Uusimaa. Conventional rehabilitation, including weekly physical therapy for 1–2 h, occupational therapy for 1 h, and pool therapy for 1–2 h, was maintained during the PAS and was the same as before the intervention. His muscle strength had remained stable prior to PAS (Supplementary Table ). Mean ± SD spontaneous changes of manual muscle test (MMT) score in the 17 months preceding PAS were 0.67 ± 0.52 (right hand) and 0.17 ± 1.17 (left hand). Pinch strength values were 0.57 ± 0.32 kg (right hand) and 0.27 ± 0.63 kg (left hand) in the 12 months preceding PAS (Supplementary Table ). Medication is presented in Supplementary Table .\nNavigated TMS (nTMS) of the motor cortex was delivered by a NBS 4.3 stimulator (Nexstim Ltd., Helsinki, Finland) with a figure-of-eight coil (outer diameter 70 mm, biphasic pulse). Structural T1-weighted MRI for nTMS was obtained with a 3T Siemens Verio scanner (Siemens Healthcare, Erlangen, Germany). The nTMS system enables accurate, reproducible stimulation of selected cortical sites, the “hotspots” , where MEPs are most readily elicited from the selected muscles . The hotspots were defined for abductor pollicis brevis (APB), abductor digiti minimi (ADM), and brachioradialis (BR) muscles in both hands as in our previous studies .\nPNS was delivered using a Dantec Keypoint electroneuromyography device (Natus Medical Inc., Pleasanton, CA, USA) and surface electrodes . The nerves were stimulated as in our previous studies . Initially, PNS stimuli were 50-Hz trains (1-ms square pulses, 6 pulses per train, train duration 100 ms). From week 30 onwards, 100-Hz trains (train duration 50 ms) were used as they were experimentally proven to be more efficient for MEP potentiation in healthy subjects .\nFor PAS , nTMS (single-pulse, 0.2 Hz, 100% MSO) of the selected hotspots was synchronized with the first pulse of the PNS train given to the corresponding contralateral nerve . The interstimulus interval for each pair was calculated using individual parameters . The subject was seated comfortably during PAS. One session consisted of PAS of 3–6 hotspot-nerve pairs given in pseudo-random order of 1.5–3 h duration in total (20 min per nerve plus time for preparations, Fig. ).\nThe hand motor training (MT) combined with the PAS (PAS-MT) was aimed at increasing muscle strength in those muscles where MMT scores remained 2 or less after 24 weeks of the intervention. Three weak muscles in the right hand were trained with motor tasks (thumb palmar abduction for APB; spreading fingers for dorsal interossei; and thumb radial abduction for abductor pollicis longus) simultaneously with the corresponding PAS. AR manually assisted the subject in finger movements.\nThe intervention of 56 weeks included 47 weeks of PAS and 1–2-week breaks without stimulations . PAS to a hotspot-nerve pair was stopped when strength and range of motion of all muscles innervated by this nerve reached an MMT score of 4–5. All left-hand muscles reached this level at week 28; only the right hand was stimulated thereafter. At subject’s request, PAS of the left median nerve and the associated motor task were reinitiated at week 40 to enable more fluent grasp movements. The follow-up period started when the MMT scores of all evaluated muscles of both hands reached level 4 or 5 and was continued for 32 weeks. All tests were performed immediately prior to the study, during the intervention, and follow up.\nOutcome measures in both hands included MMT (total scores for all evaluated muscles and partial scores of the muscles innervated by each of the stimulated nerves) and the modified Ashworth scale (MAS, spasticity in wrist and elbow) evaluated by a physiotherapist specialized in SCI and blinded to the intervention changes and results of previous evaluations. In addition, we collected sensory scores of the American Spinal Injury Association impairment scale (AIS); grip strength assessed with the adjustable-handle Jamar dynamometer (Asimov Engineering Co., MA, USA); tip, key, and palmar pinch assessed with the pinch gauge (B&L Engineering, CA, USA); the spinal cord independence measure (SCIM); the box and block (BB) test; the nine hole peg test (NHPT); and MEPs and F-responses recorded from APB, ADM, and BR . For the MMT, only muscles that scored <5 in the first assessment were selected for further evaluation (Supplementary Table 2 parts 1, 2). The subject reported subjective functional changes.\nThe total and partial MMT scores were improved in both hands . In total, the left hand regained 19 points and the right hand 48 points during the intervention. The scores reached the maximum level in the left hand after 47 weeks and remained stable in follow up. MMT scores of level 4 or 5 in the right-hand muscles were obtained in follow up. MMT scores were improved further during the PAS-MT, particularly in the right hand (Supplementary Table 2 part 1). AIS sensory scores did not differ (Supplementary Table ). Spasticity assessed with MAS remained 0 at all times. Increased grip and pinch strengths were observed in both hands already after 8–20 weeks of PAS. Remarkably, all tested pinch strength types were increased (Supplementary Table ). In the right hand, grip and pinch strength increased during the first 8–20 PAS weeks and stabilized thereafter. In the left hand, the increase in pinch strength stabilized after 25 weeks of PAS. Grip strength increased in the right hand by 4.5 kg and in the left hand by 3.3 kg . Pinch strength increased in the right hand by 3.0 kg and in the left hand by 2.6 kg, (Supplementary Table ). PAS-MT further increased pinch strength. Pinch strength decreased towards the level observed before PAS-MT administration in follow up. Results of the BB test increased from 45/68 (right hand/left hand) blocks to 52/75 blocks. By the end of the intervention, the NHPT time decreased by 31 s in the left and by 32 s in the right hand (Supplementary Table ) and remained stable during follow up in the left hand (see Supplementary Video ). The subject’s self-care and indoor and outdoor mobility increased during the PAS and improved further during follow up. His SCIM self-care score increased from 3 to 13 and SCIM indoor mobility from 6 to 10 . Respiration and sphincter management did not change. Before PAS, the subject needed total or partial assistance in eating, bathing, dressing, and grooming. During follow up, he could perform these tasks independently and without adaptive devices. In total, the subject’s SCIM score increased from 40 to 56 (Supplementary Table ). He enhanced his coherent motor control after 8 weeks of PAS (see Supplementary Videos and ), and reported numerous improvements in both hands during follow up . He regained the ability to perform various complex fine motor tasks without external help. Before intervention, the subject had pain and uncomfortable tingling that decreased or completely disappeared during the intervention and follow-up (Supplementary Table ).\nThe PAS potentiated MEPs in five out of six targeted muscles . The overall effect differed slightly between the right and left hands. In all six muscles, the MEP amplitudes in both hands increased on average by 324% after 16 weeks of follow up when compared with the corresponding values obtained prior to PAS. Before treatment it was not possible to elicit MEPs from the right ADM even with muscle preactivation. MEPs were detected after 42 weeks of stimulation and remained stable during follow up. In the left ADM, small MEPs were elicited before PAS. Their amplitudes increased during PAS and follow up. Although the changes were variable, the total amplitude increase was systematic when the first and last MEP recordings were compared . The minimum F-response latencies (F min) in the right hand decreased after PAS from 32 to 25 ms (23%) for the ulnar nerve and from 31 to 28 ms (9%) for the median nerve. No response was found with the left median nerve before intervention but was obtained during follow up (F min = 33 ms). F-min latency in the left ulnar nerve (31 ms) did not change. F-responses to the radial nerve stimulation in both hands were inconsistent. No amplitude changes were observed.\nAround week 12, during PAS of the right radial nerve the subject reported a sensation in both legs resembling electrical stimulation, leg spasticity, and spasticity-related leg pain. A simultaneous urinary tract infection unrelated to stimulation was detected and treated. Psychological stress unrelated to stimulation occurred simultaneously. The PAS was interrupted for 2 weeks and the subject increased pain medication. After that he reported a decrease in spasticity and pain. The subject’s position in the chair was adjusted to increase comfort, and PNS intensity was slightly decreased . During weeks 16–19 these symptoms gradually disappeared. No other adverse effects were reported.", + "fulltext_subclaims": [ + "The subject was a 46-year-old male with an incomplete tetraplegia (AIS B, neurological level C7), 5 years post injury.", + "The study was approved by the Ethics Committee of the Hospital District of Helsinki and Uusimaa.", + "Conventional rehabilitation, including weekly physical therapy for 1–2 h, occupational therapy for 1 h, and pool therapy for 1–2 h, was maintained during the PAS.", + "The conventional rehabilitation was the same as before the intervention.", + "The subject’s muscle strength had remained stable prior to PAS.", + "Mean ± SD spontaneous changes of manual muscle test (MMT) score in the 17 months preceding PAS were 0.67 ± 0.52 (right hand) and 0.17 ± 1.17 (left hand).", + "Pinch strength values were 0.57 ± 0.32 kg (right hand) and 0.27 ± 0.63 kg (left hand) in the 12 months preceding PAS.", + "Navigated TMS (nTMS) of the motor cortex was delivered by a NBS 4.3 stimulator.", + "The nTMS system enables accurate, reproducible stimulation of selected cortical sites.", + "The hotspots were defined for abductor pollicis brevis (APB), abductor digiti minimi (ADM), and brachioradialis (BR) muscles in both hands.", + "PNS was delivered using a Dantec Keypoint electroneuromyography device.", + "Initially, PNS stimuli were 50-Hz trains (1-ms square pulses, 6 pulses per train, train duration 100 ms).", + "From week 30 onwards, 100-Hz trains (train duration 50 ms) were used.", + "For PAS, nTMS (single-pulse, 0.2 Hz, 100% MSO) of the selected hotspots was synchronized with the first pulse of the PNS train given to the corresponding contralateral nerve.", + "The interstimulus interval for each pair was calculated using individual parameters.", + "One session consisted of PAS of 3–6 hotspot-nerve pairs given in pseudo-random order.", + "One session had a total duration of 1.5–3 h.", + "The hand motor training (MT) combined with the PAS (PAS-MT) was aimed at increasing muscle strength in those muscles where MMT scores remained 2 or less after 24 weeks of the intervention.", + "Three weak muscles in the right hand were trained with motor tasks simultaneously with the corresponding PAS.", + "The intervention of 56 weeks included 47 weeks of PAS and 1–2-week breaks without stimulations.", + "PAS to a hotspot-nerve pair was stopped when strength and range of motion of all muscles innervated by this nerve reached an MMT score of 4–5.", + "All left-hand muscles reached this level at week 28.", + "Only the right hand was stimulated thereafter.", + "At the subject’s request, PAS of the left median nerve and the associated motor task were reinitiated at week 40.", + "The follow-up period started when the MMT scores of all evaluated muscles of both hands reached level 4 or 5.", + "The follow-up period was continued for 32 weeks.", + "Outcome measures included MMT (total scores for all evaluated muscles and partial scores of the muscles innervated by each of the stimulated nerves).", + "Outcome measures included the modified Ashworth scale (MAS, spasticity in wrist and elbow).", + "Outcome measures included the American Spinal Injury Association sensory scores.", + "Outcome measures included grip strength assessed with the adjustable-handle Jamar dynamometer.", + "Outcome measures included tip, key, and palmar pinch assessed with the pinch gauge.", + "Outcome measures included the spinal cord independence measure (SCIM).", + "Outcome measures included the box and block (BB) test.", + "Outcome measures included the nine hole peg test (NHPT).", + "Outcome measures included MEPs and F-responses recorded from APB, ADM, and BR.", + "The total and partial MMT scores were improved in both hands.", + "The left hand regained 19 points and the right hand 48 points during the intervention.", + "The scores reached the maximum level in the left hand after 47 weeks.", + "MMT scores of level 4 or 5 in the right-hand muscles were obtained in follow up.", + "MMT scores were improved further during the PAS-MT, particularly in the right hand.", + "AIS sensory scores did not differ.", + "Spasticity assessed with MAS remained 0 at all times.", + "Increased grip and pinch strengths were observed in both hands already after 8–20 weeks of PAS.", + "All tested pinch strength types were increased.", + "In the right hand, grip and pinch strength increased during the first 8–20 PAS weeks and stabilized thereafter.", + "In the left hand, the increase in pinch strength stabilized after 25 weeks of PAS.", + "Grip strength increased in the right hand by 4.5 kg and in the left hand by 3.3 kg.", + "Pinch strength increased in the right hand by 3.0 kg and in the left hand by 2.6 kg.", + "PAS-MT further increased pinch strength.", + "Pinch strength decreased towards the level observed before PAS-MT administration in follow up.", + "Results of the BB test increased from 45/68 (right hand/left hand) blocks to 52/75 blocks.", + "By the end of the intervention, the NHPT time decreased by 31 s in the left and by 32 s in the right hand.", + "The subject’s self-care and indoor and outdoor mobility increased during the PAS and improved further during follow up.", + "The subject’s SCIM self-care score increased from 3 to 13.", + "The subject’s SCIM indoor mobility score increased from 6 to 10.", + "Respiration and sphincter management did not change.", + "Before PAS, the subject needed total or partial assistance in eating, bathing, dressing, and grooming.", + "During follow up, the subject could perform these tasks independently and without adaptive devices.", + "The subject’s SCIM score increased from 40 to 56.", + "The subject enhanced his coherent motor control after 8 weeks of PAS.", + "The subject reported numerous improvements in both hands during follow up.", + "The subject regained the ability to perform various complex fine motor tasks without external help.", + "Before intervention, the subject had pain and uncomfortable tingling that decreased or completely disappeared during the intervention and follow-up.", + "The PAS potentiated MEPs in five out of six targeted muscles.", + "The overall effect differed slightly between the right and left hands.", + "In all six muscles, the MEP amplitudes in both hands increased on average by 324% after 16 weeks of follow up when compared with the corresponding values obtained prior to PAS.", + "Before treatment it was not possible to elicit MEPs from the right ADM even with muscle preactivation.", + "MEPs were detected after 42 weeks of stimulation and remained stable during follow up.", + "In the left ADM, small MEPs were elicited before PAS.", + "Their amplitudes increased during PAS and follow up.", + "The minimum F-response latencies (F min) in the right hand decreased after PAS from 32 to 25 ms (23%) for the ulnar nerve.", + "The minimum F-response latencies (F min) in the right hand decreased after PAS from 31 to 28 ms (9%) for the median nerve.", + "No response was found with the left median nerve before intervention but was obtained during follow up (F min = 33 ms).", + "F-min latency in the left ulnar nerve (31 ms) did not change.", + "F-responses to the radial nerve stimulation in both hands were inconsistent.", + "No amplitude changes were observed.", + "Around week 12, during PAS of the right radial nerve the subject reported a sensation in both legs resembling electrical stimulation.", + "A simultaneous urinary tract infection unrelated to stimulation was detected and treated.", + "Psychological stress unrelated to stimulation occurred simultaneously.", + "The PAS was interrupted for 2 weeks.", + "The subject increased pain medication.", + "After that he reported a decrease in spasticity and pain.", + "The subject’s position in the chair was adjusted to increase comfort.", + "PNS intensity was slightly decreased.", + "During weeks 16–19 these symptoms gradually disappeared.", + "No other adverse effects were reported." + ], + "summary": "A 46-year-old man with traumatic C7 AIS B tetraplegia was administered PAS three times per week. After 24 weeks, PAS was combined with concomitant motor training of the remaining weak hand muscles. Outcome measures included the manual muscle test (MMT), motor-evoked potentials (MEPs), F-responses, hand functional tests, and the spinal cord independence measure (SCIM).", + "summary_subclaims": [ + "The patient was a 46-year-old man.", + "The patient had traumatic C7 AIS B tetraplegia.", + "The patient was administered PAS three times per week.", + "After 24 weeks, PAS was combined with concomitant motor training of the remaining weak hand muscles.", + "Outcome measures included the manual muscle test (MMT).", + "Outcome measures included motor-evoked potentials (MEPs).", + "Outcome measures included F-responses.", + "Outcome measures included hand functional tests.", + "Outcome measures included the spinal cord independence measure (SCIM)." + ] + }, + { + "id": "multiclinsum_test_455_en.txt", + "fulltext": "An 11-year-old boy was referred to his dentist for gingival sinus on the buccal side of the right mandibular second premolar.\nThe boy experienced intermittent spontaneous pain in the affected part for about 2 mo. His initial dentist referred the boy to our clinic for an incompletely formed root associated with a large radiolucency.\nAny trauma of the tooth was denied by his parents.\nHis parents denied any personal and family history.\nThe clinical signs were described as follows. Tooth # 45 was free of caries, but there was a sign of a fractured tubercle of DE on the occlusal surface. The tooth mobility was grade I, and there was a gingival fistula on the buccal side. The pyogenic fluids flowed out of the fistula under palpation . Tooth percussion was sensitive. The probing depths of the affected tooth were within a normal range.\nInitial panoramic radiography at his first visit showed that the root of tooth # 45 was fractured. A separated root apex was found apically under the main root and was almost completely formed. The main root remained immature with a thin root wall and was associated with a large radiolucency. However, the root of tooth # 35 was not erupted, and the second primary molar remained. The root development was graded as Nolla 8 .", + "fulltext_subclaims": [ + "An 11-year-old boy was referred to his dentist for gingival sinus on the buccal side of the right mandibular second premolar.", + "The boy experienced intermittent spontaneous pain in the affected part for about 2 mo.", + "His initial dentist referred the boy to our clinic for an incompletely formed root associated with a large radiolucency.", + "Any trauma of the tooth was denied by his parents.", + "His parents denied any personal and family history.", + "Tooth # 45 was free of caries.", + "There was a sign of a fractured tubercle of DE on the occlusal surface.", + "The tooth mobility was grade I.", + "There was a gingival fistula on the buccal side.", + "The pyogenic fluids flowed out of the fistula under palpation.", + "Tooth percussion was sensitive.", + "The probing depths of the affected tooth were within a normal range.", + "Initial panoramic radiography at his first visit showed that the root of tooth # 45 was fractured.", + "A separated root apex was found apically under the main root and was almost completely formed.", + "The main root remained immature with a thin root wall and was associated with a large radiolucency.", + "The root of tooth # 35 was not erupted, and the second primary molar remained.", + "The root development was graded as Nolla 8." + ], + "summary": "An 11-year-old boy was referred for gingival sinus on the buccal side of the right mandibular second premolar (tooth # 45). Clinically, tooth # 45 was free of caries, but there was a sign of a fractured tubercle of DE on the occlusal surface. Radiography showed that the root canal of tooth # 45 was widely radiolucent. A separated root apex was found apically under the main root and was nearly completely formed with an apical orifice at the apical tip. Tooth # 45 was diagnosed as tubular fracture of DE with chronic apical periodontitis. A revascularization technique was recommended to treat the tooth. At 3-mo and 1-yr follow-up, the patient remained asymptomatic. Periapical radiography revealed that the separated root tip distally drifted with closure of the apex. However, the root length and thickness of the main root did not increased.", + "summary_subclaims": [ + "An 11-year-old boy was referred for gingival sinus on the buccal side of the right mandibular second premolar (tooth # 45).", + "Tooth # 45 was free of caries.", + "There was a sign of a fractured tubercle of DE on the occlusal surface.", + "Radiography showed that the root canal of tooth # 45 was widely radiolucent.", + "A separated root apex was found apically under the main root.", + "The separated root apex was nearly completely formed with an apical orifice at the apical tip.", + "Tooth # 45 was diagnosed as tubular fracture of DE with chronic apical periodontitis.", + "A revascularization technique was recommended to treat the tooth.", + "At 3-mo and 1-yr follow-up, the patient remained asymptomatic.", + "Periapical radiography revealed that the separated root tip distally drifted with closure of the apex.", + "The root length and thickness of the main root did not increase." + ] + }, + { + "id": "multiclinsum_test_1263_en.txt", + "fulltext": "A 43-year-old African American woman presented with a painful cystic mass on the left labia majora. Preoperatively, the lesion was diagnosed as Bartholin's abscess. During the excision and drainage, an additional 2.0 × 0.8 × 0.8 cm tan-brown dermal nodule was identified and submitted for histological analysis. Microscopic examination revealed multiple pieces of fibro-necrotic tissues associated with a well-circumscribed papillary neoplasm with cystic dilation . The papillary projections and cystic areas were lined by basophilic cuboidal to columnar cells with outer compressed myoepithelial cells . There were foci of active decapitation secretion and apocrine differentiation . The diagnosis of Bartholin's abscess arising in hidradenoma papilliferum was made.", + "fulltext_subclaims": [ + "The patient is a 43-year-old African American woman.", + "She presented with a painful cystic mass on the left labia majora.", + "Preoperatively, the lesion was diagnosed as Bartholin's abscess.", + "During the excision and drainage, an additional 2.0 × 0.8 × 0.8 cm tan-brown dermal nodule was identified.", + "The nodule was submitted for histological analysis.", + "Microscopic examination revealed multiple pieces of fibro-necrotic tissues.", + "The fibro-necrotic tissues were associated with a well-circumscribed papillary neoplasm with cystic dilation.", + "The papillary projections and cystic areas were lined by basophilic cuboidal to columnar cells.", + "The outer layer of the papillary projections contained compressed myoepithelial cells.", + "There were foci of active decapitation secretion.", + "There was apocrine differentiation.", + "The diagnosis was Bartholin's abscess arising in hidradenoma papilliferum." + ], + "summary": "A 43-year-old African American woman presented with a painful cystic mass on the left labia majora. A preoperative diagnosis of Bartholin's abscess was made. During excision and draining, an additional tan-brown dermal nodule was removed which demonstrated histological features of Hidradenoma papilliferum.", + "summary_subclaims": [ + "The patient is a 43-year-old African American woman.", + "She presented with a painful cystic mass on the left labia majora.", + "A preoperative diagnosis of Bartholin's abscess was made.", + "During excision and draining, an additional tan-brown dermal nodule was removed.", + "The removed nodule demonstrated histological features of Hidradenoma papilliferum." + ] + }, + { + "id": "multiclinsum_test_348_en.txt", + "fulltext": "A previously healthy 60-year-old female seeking medical attention through teleconsultation presents with profound dyspnea, oppressive chest pain, fatigue, episodic hallucinations, and difficulty sleeping. The patient describes that her symptoms began 7 days ago with non-productive cough and fever, later progressing to dyspnea that exacerbated with minimal effort, for what she originally sought medical attention at an ER. At the ER triage the patient presented with profound dyspnea, an oxygen saturation of 86% at room air, and a respiratory rate of 32 breaths/min. However, despite the severity of the respiratory compromise, the patient could not be admitted due to hospital oversaturation. Unfortunately, the patient was sent home with medical recommendations, including nebulization with normal saline, acetylcysteine and ambroxol hydrochloride. She was also advised that a chest CT scan was needed.\nAt the medical teleconsultation, the patient presented marked respiratory distress accompanied with a respiratory rate of 31 respirations per minute, and an oxygen saturation of 85% at room air. A relative of the patient described what is compatible with skin and mucous membrane dryness, skin pallor and bilateral 1+ pitting edema. The patient handed-off a copy of the CT scan where bilateral pulmonary edema and consolidations with ground-glassing were observed encompassing nearly 90% of the lung parenchyma . A basic panel of laboratory tests, and a PCR test for COVID-19 were ordered, the latter of which confirmed the diagnosis . She was prescribed with IV normal saline for rehydration, pharmacologic management with IV methylprednisolone (250 mg every 24 h for 3 days), followed by prednisone (40 mg for 7 days), nitazoxanide (500 mg every 8 h) for 7 days and a single dose of 40 mg of subcutaneous enoxaparin, all of which were administered by an outpatient registered nurse at home. Standard oxygen therapy through nasal cannula was also recommended. Medical treatment is best depicted in Fig. . Colchicine was added at the third day of treatment (2 mg loading dose, followed by 0.5 mg every 8 h up to the end of treatment).\nDaily follow-ups were established to monitor for signs of clinical improvement. Two weeks later from the initial consultation the patient presented marked improvement in her symptoms, as well as in her CT scan , which prompted in discontinuation of the medications and the oxygen therapy. At one-month follow-up the patient presented a nearly complete resolution of the initial symptoms, with a partially restored capacity to perform her daily activities. At the 45th day a negative PCR test for the viral RNA was reported. However, spirometry and diffusion capacity for carbon monoxide (DLCO) at 3rd, 4th and 6th months showed results compatible with a restrictive pattern evidenced by reduced FVC, FEV1 and DLCO measurements with respect to predicted values , while the 6-min walk test showed a decreased walking distance. Radiographic changes persisted at the 6-month follow-up chest CT scan .", + "fulltext_subclaims": [ + "The patient is a 60-year-old female.", + "The patient is previously healthy.", + "The patient sought medical attention through teleconsultation.", + "The patient presented with profound dyspnea.", + "The patient described that her symptoms began 7 days ago.", + "The patient originally sought medical attention at an ER.", + "At the ER triage, the patient presented with an oxygen saturation of 86% at room air.", + "The patient could not be admitted due to hospital oversaturation.", + "The patient was sent home with medical recommendations.", + "The patient was advised that a chest CT scan was needed.", + "At the medical teleconsultation, the patient presented with an oxygen saturation of 85% at room air.", + "A relative described skin and mucous membrane dryness.", + "A relative described bilateral 1+ pitting edema.", + "The CT scan showed bilateral pulmonary edema.", + "The CT scan showed bilateral consolidations with ground-glassing.", + "The CT scan showed nearly 90% of the lung parenchyma affected.", + "A PCR test for COVID-19 was ordered.", + "The PCR test confirmed the diagnosis.", + "The patient was prescribed IV normal saline for rehydration.", + "The patient was prescribed IV methylprednisolone (250 mg every 24 h for 3 days).", + "The patient was prescribed prednisone (40 mg for 7 days).", + "The patient was prescribed nitazoxanide (500 mg every 8 h) for 7 days.", + "The patient was prescribed a single dose of 40 mg of subcutaneous enoxaparin.", + "Standard oxygen therapy through nasal cannula was recommended.", + "Colchicine was added at the third day of treatment.", + "Daily follow-ups were established.", + "Two weeks later, the patient presented marked improvement in her symptoms.", + "Two weeks later, the CT scan showed improvement.", + "At one-month follow-up, the patient presented a nearly complete resolution of the initial symptoms.", + "At the 45th day, a negative PCR test for the viral RNA was reported.", + "At 3rd, 4th, and 6th months, spirometry showed a restrictive pattern.", + "At 3rd, 4th, and 6th months, diffusion capacity for carbon monoxide (DLCO) showed reduced measurements.", + "Radiographic changes persisted at the 6-month follow-up chest CT scan." + ], + "summary": "A 60-year-old female seeking medical attention through teleconsultation presents with profound dyspnea, oppressive chest pain, fatigue, episodic hallucinations, and difficulty sleeping, for what she originally sought medical attention at an ER but could not be admitted due to saturation of the health system. A positive PCR test for COVID-19, and a CT scan of the chest showing bilateral consolidations with ground-glass opacities confirmed the diagnosis. The patient was managed at home, with corticosteroids, nitazoxanide and a single dose of 40 mg of subcutaneous enoxaparin. Colchicine was added at the third day of treatment. Standard oxygen therapy through nasal cannula was also recommended. Daily follow-ups were established to monitor for signs of clinical improvement. Two weeks later from the initial consultation the patient presents marked improvement in her symptoms, as well as in her CT scan, which prompted in discontinuation of the medications and the oxygen therapy.", + "summary_subclaims": [ + "The patient is a 60-year-old female.", + "The patient sought medical attention through teleconsultation.", + "The patient had profound dyspnea.", + "The patient had oppressive chest pain.", + "The patient had fatigue.", + "The patient had episodic hallucinations.", + "The patient had difficulty sleeping.", + "The patient originally sought medical attention at an ER.", + "The patient could not be admitted due to saturation of the health system.", + "A positive PCR test for COVID-19 confirmed the diagnosis.", + "A CT scan of the chest showed bilateral consolidations with ground-glass opacities.", + "The patient was managed at home.", + "The patient received corticosteroids.", + "The patient received nitazoxanide.", + "The patient received a single dose of 40 mg of subcutaneous enoxaparin.", + "Colchicine was added at the third day of treatment.", + "Standard oxygen therapy through nasal cannula was recommended.", + "Daily follow-ups were established.", + "Two weeks later from the initial consultation, the patient presented marked improvement in her symptoms.", + "The CT scan showed marked improvement two weeks later.", + "The improvement in the CT scan prompted discontinuation of the medications.", + "The improvement in the CT scan prompted discontinuation of the oxygen therapy." + ] + }, + { + "id": "multiclinsum_test_3334_en.txt", + "fulltext": "Our patient is a 32-year-old G4P1021 (Gravida 4 Para 1,021–1 term delivery, 0 preterm deliveries, 2 abortions, 1 living offspring) with a body mass index of 37 who initially presented at 8 weeks of gestation for her dating ultrasound, which depicted a fetus in the right uterine horn and an empty left uterine horn. The patient had a known history of a didelphys uterus with two uteri and two cervices diagnosed several years prior on pelvic ultrasound. No additional imaging was obtained to evaluate for renal anomalies, which limited a complete antepartum evaluation, as renal tract malformations are highly associated with Müllarian anomalies. Her obstetrical history was significant for a prior low-transverse cesarean section at full term for arrest of dilation at 1.0 cm, a dilation and evacuation for a fetus with polycystic kidney disease and secondary anhydramnios, and a medical termination of pregnancy. All four of her pregnancies were located in the right uterine horn. Throughout her antepartum course, fetal growth was within normal limits with consistent cephalic presentation.\n\nAt 39 weeks 3 days of gestation she presented in early labor at 1.0 cm dilated, 80 % effaced, at −2 station. She denied incisional pain. Her VBAC score was calculated as 35 %. She requested a TOLAC, was counseled appropriately regarding the risks and benefits, and was admitted for labor augmentation. The fetal heart rate tracing on admission was Category I with approximately three contractions in ten minutes on tocometer. She received an epidural and vaginal exam was repeated. A rudimentary cervix was palpated on the patient’s left with a slightly dilated cervix identified on the patient’s right, through which the cervical ripening balloon was placed. Both the uterine and vaginal balloons were inflated with 80 cc of normal saline. Pitocin was also started at that time.\n\nThe balloon was in place for 11 h, at which time she was 4.0 cm dilated, 50 % effaced, at −2 station with the cervix still notably on the patient’s right. Her membranes were artificially ruptured at that time for clear fluid. She became fully dilated after 22 h on pitocin. She pushed for 90 min with a Category II tracing secondary to variable decelerations. Right mediolateral episiotomy was cut to expedite delivery of a viable female infant from LOA position with 1-and 5-min APGAR scores of 6 and 9, respectively. Birthweight was 3225 g (25.5th percentile). Retained placenta was manually extracted with a total estimated blood loss of 400 cc. The episiotomy was repaired with 2–0 vicryl in the standard fashion. The patient’s postpartum course was uncomplicated and she was discharged home on postpartum day 2.", + "fulltext_subclaims": [ + "The patient is a 32-year-old G4P1021.", + "The patient has a body mass index of 37.", + "The patient initially presented at 8 weeks of gestation for her dating ultrasound.", + "The dating ultrasound depicted a fetus in the right uterine horn.", + "The dating ultrasound showed an empty left uterine horn.", + "The patient had a known history of a didelphys uterus with two uteruses and two cervices.", + "The didelphys uterus was diagnosed several years prior on pelvic ultrasound.", + "No additional imaging was obtained to evaluate for renal anomalies.", + "The patient had a prior low-transverse cesarean section at full term for arrest of dilation at 1.0 cm.", + "The patient had a dilation and evacuation for a fetus with polycystic kidney disease and secondary anhydramnios.", + "The patient had a medical termination of pregnancy.", + "All four of her pregnancies were located in the right uterine horn.", + "Throughout her antepartum course, fetal growth was within normal limits.", + "Fetal growth was consistent with cephalic presentation.", + "At 39 weeks 3 days of gestation, she presented in early labor at 1.0 cm dilated.", + "She was 80 % effaced at −2 station.", + "She requested a TOLAC.", + "She was counseled appropriately regarding the risks and benefits.", + "She was admitted for labor augmentation.", + "The fetal heart rate tracing on admission was Category I.", + "She received an epidural.", + "A rudimentary cervix was palpated on the patient’s left.", + "A slightly dilated cervix was identified on the patient’s right.", + "The cervical ripening balloon was placed through the right cervix.", + "Both the uterine and vaginal balloons were inflated with 80 cc of normal saline.", + "Pitocin was started at that time.", + "The balloon was in place for 11 h.", + "She was 4.0 cm dilated, 50 % effaced, at −2 station after 11 h.", + "Her membranes were artificially ruptured at that time for clear fluid.", + "She became fully dilated after 22 h on pitocin.", + "She pushed for 90 min with a Category II tracing secondary to variable decelerations.", + "Right mediolateral episiotomy was cut to expedite delivery.", + "A viable female infant was delivered from LOA position.", + "The 1-min APGAR score was 6.", + "The 5-min APGAR score was 9.", + "The birthweight was 3225 g.", + "The birthweight was at the 25.5th percentile.", + "Retained placenta was manually extracted.", + "The total estimated blood loss was 400 cc.", + "The episiotomy was repaired with 2–0 vicryl in the standard fashion.", + "The patient’s postpartum course was uncomplicated.", + "The patient was discharged home on postpartum day 2." + ], + "summary": "Our patient is a 32-year-old G4P1021 (Gravida 4 Para 1,021–1 term delivery, 0 preterm deliveries, 2 abortions, 1 living offspring) who presented at 8 weeks of gestation with a known history of a didelphys uterus. Her obstetrical history was significant for a prior low-transverse cesarean section at term. All four of her pregnancies were located in the right uterine horn. At 39 weeks 3 days of gestation she presented in early labor and requested a TOLAC. She received an epidural, a cervical ripening balloon was placed, and she was started on pitocin. She pushed to deliver a viable infant. The patient’s postpartum course was uncomplicated, and she was discharged home on postpartum day two.", + "summary_subclaims": [ + "The patient is a 32-year-old G4P1021.", + "She presented at 8 weeks of gestation.", + "She has a known history of a didelphys uterus.", + "Her obstetrical history was significant for a prior low-transverse cesarean section at term.", + "All four of her pregnancies were located in the right uterine horn.", + "She presented at 39 weeks 3 days of gestation in early labor.", + "She requested a TOLAC.", + "She received an epidural.", + "A cervical ripening balloon was placed.", + "She was started on pitocin.", + "She pushed to deliver a viable infant.", + "The patient’s postpartum course was uncomplicated.", + "She was discharged home on postpartum day two." + ] + }, + { + "id": "multiclinsum_test_3177_en.txt", + "fulltext": "A 46-year-old female with a history of classical HL nodular sclerosis subtype complained of a right cervical lymph node enlargement after 3 cycles of first-line chemotherapy ABVD (adriamycin, bleomycin, vinblastine, and dacarbazine) three months ago. There were no fever, night sweats, and weight loss. She had no other pre-existing illness. On physical examinations, we found an enlargement of multiple right anterior cervical lymph nodes. No tenderness and no signs of inflammation.\n\nThe surgeon performed an excisional biopsy to confirm the refractory of the disease. The cervical lymph node biopsy specimen (Hematoxylin & Eosin staining (H&E)) showed lymph nodes with nodular growth pattern surrounded by collagen bands. There were Hodgkin Reed-Sternberg cells, lacunar cells, small lymphocytes, and other inflammatory cells as background. The immunohistochemistry (IHC) showed positive for CD 30, CD 15, and MUM1, dim positive for PAX. The morphological features and IHC result confirmed the classical HL nodular sclerosis subtype; therefore, we established the diagnosis of refractory nodular sclerosis HL.\n\nWe performed 18-Fluorodeoxyglucose positron emission tomography (PET) scan for staging and revealed lymph nodes involvement of right inferior jugular, right posterior cervical, right supraclavicular, right superior paratracheal, aorta para-arcus, aortopulmonary window, upper lobe of the left lung, peritoneum, and mesenterial with diffuse metabolic activity of all bone marrow. These findings are suggested as an extranodal extension. We did not find metastatic lung disease. Clinical staging was restaged with Clinical Stage (CS) IV according to the Ann-Arbor staging system.\n\nWe offered salvage treatment with conventional chemotherapy with DHAP followed by HDT and ASCT; however, the patient hesitated since she was worried about the toxicities which could make her more susceptible to getting COVID-19 infection in the era of the COVID-19 pandemic. After discussion and explanation to the patient and the family about the efficacy and side-effect profile of BV, finally, the patient chose BV for second-line treatment to control the tumor. We administered BV monotherapy 1.8 mg/m2 every 3 weeks for up to 16 cycles. The patient tolerated BV well for eight cycles without any significant toxicities and side effects. We stopped the administration of BV because the patient had already reached remission after 8 cycles, and she was not willing to continue the chemotherapy until 16 cycles. The evaluation of the PET scan after the end of cycle-8 showed complete remission. We then suggested the patient to control every 3 months to observe the remission status with HDT and ASCT as an option to salvage if the cHL further relapsed.", + "fulltext_subclaims": [ + "The patient is a 46-year-old female.", + "She has a history of classical HL nodular sclerosis subtype.", + "She complained of right cervical lymph node enlargement.", + "She had three cycles of first-line chemotherapy ABVD three months ago.", + "There were no fever, night sweats, and weight loss.", + "She had no other pre-existing illness.", + "On physical examination, multiple right anterior cervical lymph nodes were enlarged.", + "No tenderness was found.", + "No signs of inflammation were found.", + "An excisional biopsy was performed.", + "The cervical lymph node biopsy specimen showed lymph nodes with a nodular growth pattern surrounded by collagen bands.", + "Hodgkin Reed-Sternberg cells were present.", + "Lacunar cells were present.", + "Small lymphocytes were present.", + "Other inflammatory cells were present as background.", + "The immunohistochemistry showed positive for CD 30.", + "The immunohistochemistry showed positive for CD 15.", + "The immunohistochemistry showed positive for MUM1.", + "The immunohistochemistry showed dim positive for PAX.", + "The morphological features and IHC result confirmed the classical HL nodular sclerosis subtype.", + "The diagnosis was established as refractory nodular sclerosis HL.", + "An 18-Fluorodeoxyglucose PET scan was performed.", + "The PET scan revealed lymph nodes involvement of right inferior jugular, right posterior cervical, right supraclavicular, right superior paratracheal, aorta para-arcus, aortopulmonary window, upper lobe of the left lung, peritoneum, and mesenterial.", + "The PET scan showed diffuse metabolic activity of all bone marrow.", + "The findings are suggested as an extranodal extension.", + "Metastatic lung disease was not found.", + "The clinical staging was restaged with Clinical Stage IV according to the Ann-Arbor staging system.", + "Salvage treatment with conventional chemotherapy with DHAP followed by HDT and ASCT was offered.", + "The patient hesitated due to concerns about toxicities and susceptibility to COVID-19.", + "The patient chose BV for second-line treatment.", + "BV monotherapy 1.8 mg/m2 every 3 weeks for up to 16 cycles was administered.", + "The patient tolerated BV well for eight cycles without significant toxicities.", + "BV was stopped after 8 cycles.", + "The patient had already reached remission after 8 cycles.", + "The patient was not willing to continue chemotherapy until 16 cycles.", + "The PET scan after cycle-8 showed complete remission.", + "The patient was suggested to be controlled every 3 months.", + "HDT and ASCT were suggested as an option to salvage if the cHL further relapsed." + ], + "summary": "A 46-year-old female with a history of cHL nodular sclerosis subtype was presented with right cervical lymph node enlargement, after 3 cycles of first-line chemotherapy ABVD (adriamycin, bleomycin, vinblastine, and dacarbazine) 3 months ago. She was afraid to undergo second-line chemotherapy in the era of pandemic COVID-19 because of the side effects and toxicities; therefore, she was given 8 cycles of BV as monotherapy. The response of the treatment was complete remission.", + "summary_subclaims": [ + "The patient is a 46-year-old female.", + "She has a history of cHL nodular sclerosis subtype.", + "She presented with right cervical lymph node enlargement.", + "She had 3 cycles of first-line chemotherapy ABVD 3 months ago.", + "She was afraid to undergo second-line chemotherapy in the era of pandemic COVID-19.", + "She was given 8 cycles of BV as monotherapy.", + "The response of the treatment was complete remission." + ] + }, + { + "id": "multiclinsum_test_765_en.txt", + "fulltext": "The patient is a 71-year-old man who presented with abdominal discomfort and vomiting after a meal. Upper gastrointestinal endoscopy revealed a tumor in the duodenal bulb, and he was referred to our hospital for further examination and treatment. Laboratory tests revealed anemia, elevation of CEA (87.0 ng/ml) and CA19-9 (136 ng/ml), and a normal total bilirubin value (0.7 mg/dl). He underwent upper gastrointestinal endoscopy again, which revealed an irregular tumor occupying the lumen of the duodenal bulb, and the 2nd portion could not be observed. The biopsy result was adenocarcinoma . CT scan revealed a 10-cm tumor with poor contrast effect in the pancreatic head region, and a 6-cm tumor thrombus was observed from the superior mesenteric vein to the junction of the portal and splenic vein . Invasion into the gastroduodenal artery was suspected, but no invasion into the celiac or superior mesenteric arteries was revealed. MRCP showed no significant dilation of the common bile duct or main pancreatic duct . In abdominal ultrasonography, the lesion invading the superior mesenteric vein was considered to be a tumor thrombus with an echogenic region in the vascular lumen . After admission, frequent blood transfusions were required due to bleeding from the tumor. There were no problems with cardiopulmonary function and no evidence of distant metastasis. He was diagnosed with primary pancreatic cancer or primary duodenal cancer with portal vein tumor thrombus. We planned to perform pancreatoduodenectomy combined with portal vein resection to cure and relieve the symptoms.\nAt operation, a large tumor was found in the head of the pancreas and the descending duodenum . GDA was not involved. There were no obvious findings of peritoneal dissemination or liver metastasis, so we performed pancreaticoduodenectomy, with combined resection of the portal vein replaced by the right external iliac vein graft . The caudal limit of the tumor thrombus was just above the first branch of the SMV, and the SMV was cut at one orifice. The cranial side of the portal vein was cut in the hepatoduodenal ligament, and the splenic vein was ligated. The portal vein was reconstructed by the interposition of the right external iliac vein graft. The portal vein flow was gradually interrupted by thrombosis formation so that collateral vessels developed. SMV flow was completely blocked, and the flow seemed to run through collateral vessels. This made surgery difficult due to hemorrhage. On the other hand, temporary bypass was not necessary because collateral vessels were well developed. The operation time was 615 min, and blood loss was 2405 g. The resected specimen showed a large tumor occupying the head of the pancreas and invading the duodenal lumen . The tumor showed a gelatinous appearance on cross section and was mainly located in the pancreas head. The tumor size was 105 × 70 × 100 mm in three dimensions. Histopathological findings showed colloid carcinoma of the pancreas, as adenocarcinoma cells floating in the mucus lake were observed . No adenomatous lesions were observed in the adjacent duodenum mucosa. There was a tumor thrombus in the portal vein. Tumor thrombi were also observed in small vessels within and around the tumor bed . Because we did not observe any distinct evidence of direct cancer involvement into the portal vein , we considered that this tumor thrombus in the portal vein was formed by intravascular extension through venous vessels. According to the general rules of the AICC/UICC 8th edition TNM staging system, the tumor was described as pT3N0M0. The resection margin was positive for the tumor thrombus at the proximal stump of the portal vein. Immunohistochemistry studies showed that it was CK7+, CK20−, CA19-9+, CK19+, and CDX-2+, which were consistent with colloid carcinoma of the pancreas.\nThe postoperative course was uneventful, and there were no complications, including pancreatic fistula. He was discharged from the hospital approximately 2 months after the operation after moving to the rehabilitation ward. He moved to the rehabilitation ward not only for medical reasons, but also for social reasons. After 6 weeks of surgery, S-1 was administered as adjuvant chemotherapy, which was discontinued and switched to gemcitabine monotherapy as he had severe diarrhea. Liver metastases appeared 12 months postoperatively, so gemcitabine was used in combination with nab-paclitaxel for 2 months. However, his physical status worsened, and chemotherapy was discontinued. He died at home 16 months after the operation.", + "fulltext_subclaims": [ + "The patient is a 71-year-old man.", + "He presented with abdominal discomfort and vomiting after a meal.", + "Upper gastrointestinal endoscopy revealed a tumor in the duodenal bulb.", + "He was referred to our hospital for further examination and treatment.", + "Laboratory tests revealed anemia.", + "CEA was elevated to 87.0 ng/ml.", + "CA19-9 was elevated to 136 ng/ml.", + "Total bilirubin was 0.7 mg/dl.", + "Upper gastrointestinal endoscopy revealed an irregular tumor occupying the lumen of the duodenal bulb.", + "The 2nd portion could not be observed.", + "The biopsy result was adenocarcinoma.", + "CT scan revealed a 10-cm tumor with poor contrast effect in the pancreatic head region.", + "A 6-cm tumor thrombus was observed from the superior mesenteric vein to the junction of the portal and splenic vein.", + "Invasion into the gastroduodenal artery was suspected.", + "No invasion into the celiac or superior mesenteric arteries was revealed.", + "MRCP showed no significant dilation of the common bile duct or main pancreatic duct.", + "Abdominal ultrasonography showed a lesion invading the superior mesenteric vein considered to be a tumor thrombus with an echogenic region in the vascular lumen.", + "Frequent blood transfusions were required due to bleeding from the tumor.", + "There were no problems with cardiopulmonary function.", + "There was no evidence of distant metastasis.", + "He was diagnosed with primary pancreatic cancer or primary duodenal cancer with portal vein tumor thrombus.", + "We planned to perform pancreatoduodenectomy combined with portal vein resection.", + "At operation, a large tumor was found in the head of the pancreas and the descending duodenum.", + "GDA was not involved.", + "There were no obvious findings of peritoneal dissemination or liver metastasis.", + "We performed pancreaticoduodenectomy with combined resection of the portal vein replaced by the right external iliac vein graft.", + "The caudal limit of the tumor thrombus was just above the first branch of the SMV.", + "The SMV was cut at one orifice.", + "The cranial side of the portal vein was cut in the hepatoduodenal ligament.", + "The splenic vein was ligated.", + "The portal vein was reconstructed by the interposition of the right external iliac vein graft.", + "The portal vein flow was gradually interrupted by thrombosis formation so that collateral vessels developed.", + "SMV flow was completely blocked, and the flow seemed to run through collateral vessels.", + "This made surgery difficult due to hemorrhage.", + "Temporary bypass was not necessary because collateral vessels were well developed.", + "The operation time was 615 min.", + "Blood loss was 2405 g.", + "The resected specimen showed a large tumor occupying the head of the pancreas and invading the duodenal lumen.", + "The tumor showed a gelatinous appearance on cross section and was mainly located in the pancreas head.", + "The tumor size was 105 × 70 × 100 mm in three dimensions.", + "Histopathological findings showed colloid carcinoma of the pancreas.", + "No adenomatous lesions were observed in the adjacent duodenum mucosa.", + "There was a tumor thrombus in the portal vein.", + "Tumor thrombi were also observed in small vessels within and around the tumor bed.", + "We did not observe any distinct evidence of direct cancer involvement into the portal vein.", + "We considered that this tumor thrombus in the portal vein was formed by intravascular extension through venous vessels.", + "According to the general rules of the AICC/UICC 8th edition TNM staging system, the tumor was described as pT3N0M0.", + "The resection margin was positive for the tumor thrombus at the proximal stump of the portal vein.", + "Immunohistochemistry studies showed CK7+.", + "Immunohistochemistry studies showed CK20−.", + "Immunohistochemistry studies showed CA19-9+.", + "Immunohistochemistry studies showed CK19+.", + "Immunohistochemistry studies showed CDX-2+.", + "These findings were consistent with colloid carcinoma of the pancreas.", + "The postoperative course was uneventful.", + "There were no complications, including pancreatic fistula.", + "He was discharged from the hospital approximately 2 months after the operation after moving to the rehabilitation ward.", + "He moved to the rehabilitation ward not only for medical reasons, but also for social reasons.", + "After 6 weeks of surgery, S-1 was administered as adjuvant chemotherapy.", + "S-1 was discontinued and switched to gemcitabine monotherapy as he had severe diarrhea.", + "Liver metastases appeared 12 months postoperatively.", + "Gemcitabine was used in combination with nab-paclitaxel for 2 months.", + "His physical status worsened, and chemotherapy was discontinued.", + "He died at home 16 months after the operation." + ], + "summary": "A 71-year-old man visited a clinic with complaints of abdominal discomfort and vomiting. Gastroscopy showed a massive tumor in the duodenum. He was referred to our hospital for further examinations and treatment. The CT showed a low-density tumor with a maximum diameter of 10 cm located on the pancreas head. A tumor widely invaded the duodenum and had a 6-cm portal vein tumor thrombus. MRCP did not show obvious stenosis of the pancreatic duct due to tumor invasion. There were no findings suggesting distant metastases. Biopsy of the duodenum revealed adenocarcinoma. He was diagnosed with primary pancreatic cancer or duodenal cancer with portal vein tumor thrombus and underwent pancreatoduodectomy with resection and reconstruction of the portal vein. He suffered no postoperative complications and was discharged 2 months after surgery. The final histopathological diagnosis was pancreatic colloid carcinoma. He received adjuvant chemotherapy, but died 16 months after surgery.", + "summary_subclaims": [ + "A 71-year-old man visited a clinic with complaints of abdominal discomfort and vomiting.", + "Gastroscopy showed a massive tumor in the duodenum.", + "He was referred to our hospital for further examinations and treatment.", + "The CT showed a low-density tumor with a maximum diameter of 10 cm located on the pancreas head.", + "A tumor widely invaded the duodenum.", + "The tumor had a 6-cm portal vein tumor thrombus.", + "MRCP did not show obvious stenosis of the pancreatic duct due to tumor invasion.", + "There were no findings suggesting distant metastases.", + "Biopsy of the duodenum revealed adenocarcinoma.", + "He was diagnosed with primary pancreatic cancer or duodenal cancer with portal vein tumor thrombus.", + "He underwent pancreatoduodectomy with resection and reconstruction of the portal vein.", + "He suffered no postoperative complications.", + "He was discharged 2 months after surgery.", + "The final histopathological diagnosis was pancreatic colloid carcinoma.", + "He received adjuvant chemotherapy.", + "He died 16 months after surgery." + ] + }, + { + "id": "multiclinsum_test_2031_en.txt", + "fulltext": "A 71-year-old woman with suspected AvWD was referred to our clinic for the first time in February, 2010 and treated from 2010 to 2022. Her past medical history included a normal pregnancy at 24 years of age, mastectomy, radiotherapy and chemotherapy for carcinoma of the left breast at 38 years, lacrimal duct agenesis surgery at 51 years, and meniscus tear surgery at 67 years of age. No complications or bleeding were associated with any of these treatments. The patient was in complete remission from the carcinoma. The patient was diagnosed with advanced arthrosis in the right knee and hip aged 60. Cardiovascular risk factors including dyslipidaemia, hypertension, hyperglycaemia and obesity were recorded. A family history of bleeding was noted.\nSignificant history included the development of frequent epistaxis and bleeding following a dental extraction at the age of 60 years. The patient was treated at our clinic over a period of 12 years (2010–2022) for retinal haemorrhage; recurrent hemarthrosis; and advanced gonarthrosis. The patient had poorly controlled pain and required treatment with oxycodone hydrochloride, paracetamol, metamizole, and infiltrations with triamcinolone 40 mg and ropivacaine (0.1% at a total dose of 8 ml) every 6–8 months. This case report follows the guidance of SCARE (Surgical Case Report) criteria.", + "fulltext_subclaims": [ + "The patient is a 71-year-old woman.", + "The patient was referred to the clinic for the first time in February 2010.", + "The patient was treated from 2010 to 2022.", + "The patient had a normal pregnancy at 24 years of age.", + "The patient had a mastectomy, radiotherapy, and chemotherapy for carcinoma of the left breast at 38 years.", + "The patient had lacrimal duct agenesis surgery at 51 years.", + "The patient had meniscus tear surgery at 67 years of age.", + "No complications or bleeding were associated with any of the treatments.", + "The patient was in complete remission from the carcinoma.", + "The patient was diagnosed with advanced arthrosis in the right knee and hip at 60 years of age.", + "The patient had cardiovascular risk factors including dyslipidaemia, hypertension, hyperglycaemia, and obesity.", + "A family history of bleeding was noted.", + "The patient had frequent epistaxis.", + "The patient had bleeding following a dental extraction at 60 years of age.", + "The patient was treated at the clinic from 2010 to 2022.", + "The patient was treated for retinal haemorrhage.", + "The patient had recurrent hemarthrosis.", + "The patient had advanced gonarthrosis.", + "The patient required treatment with oxycodone hydrochloride, paracetamol, and metamizole.", + "The patient had infiltrations with triamcinolone 40 mg and ropivacaine 0.1% at a total dose of 8 ml every 6–8 months.", + "This case report follows the guidance of SCARE criteria." + ], + "summary": "Here, the authors report a patient with AvWD requiring a knee prosthesis implantation due to chronic pain, limited range of motion and functional impairment. The patient had a high risk of bleeding during surgery and was at risk of thrombosis due to age and obesity.", + "summary_subclaims": [ + "The patient had AvWD.", + "The patient required a knee prosthesis implantation.", + "The patient had chronic pain.", + "The patient had limited range of motion.", + "The patient had functional impairment.", + "The patient had a high risk of bleeding during surgery.", + "The patient was at risk of thrombosis.", + "The patient's risk of thrombosis was due to age and obesity." + ] + }, + { + "id": "multiclinsum_test_2871_en.txt", + "fulltext": "An 81-year-old man presented with abdominal discomfort. Computed tomography imaging revealed a large tumor with intermediate signal intensity, showing heterogeneous contrast enhancement in the subphrenic area and the feeding artery originated from the diaphragm . Within several days, he suddenly experienced loss of consciousness. Serum examination indicated hypoglycemia (glucose levels, 18 mg/dL). Insulin (1.05 μIU/mL), C-peptide (0.71 ng/ml), and IGF1 (39 ng/mL) levels were all relatively low but still within the physiological range. Western blot analysis of the patient’s serum revealed overexpression of high-molecular-weight IGF-2 designated “big IGF-2” . Along with glucose compensation, the patient underwent surgery for total tumor resection. In the operative view, the large tumor appeared to compress the right lobe of the liver without invasion. The feeding artery originating from the diaphragm was ligated and divided. A part of the diaphragm was resected with autosuture owing to firm adherence of the diaphragm to the artery. The tumor was then dissected along the liver surface without simultaneous resection of any other organs, and a tumor-free margin was achieved macroscopically. The tumor measured 34 cm at the major axis and weighed 1350 g and was well demarcated by a fibrous membrane. The resected surface was elastic, firm, had an ivory-like appearance, and was multilobulated with trabeculation. The solid component was predominant, and a small myxoid component was also noted . Microscopically, spindle cells generally constituted the tumor without specific cellular arrangement in the solid component . A few areas in this component demonstrated keloid-like collagenous stroma and stag horn-like vessels. However, some areas with myxoid appearance upon gross examination revealed a multi-cystic formation by cavernous hemangioma-like septa. Karyokinesis was detected in more than 0/10 high-power fields in the hypercellular area. Necrosis was obscure. Immunohistochemically, the tumor cells expressed STAT6 and CD34. The highest Ki-67 labeling index was 15%. These results confirmed that the tumor was a malignant SFT. In addition, the tumor cells exhibited cytoplasmic IGF2 expression , specifically with paranuclear dot-like reactivity. The tumor cells were positive for IGF2R but negative for IGF1R. Since surgery, the patient has been free from tumor recurrence and hypoglycemia for more than 24 months.", + "fulltext_subclaims": [ + "An 81-year-old man presented with abdominal discomfort.", + "Computed tomography imaging revealed a large tumor with intermediate signal intensity.", + "The tumor showed heterogeneous contrast enhancement in the subphrenic area.", + "The feeding artery originated from the diaphragm.", + "Within several days, he suddenly experienced loss of consciousness.", + "Serum examination indicated hypoglycemia (glucose levels, 18 mg/dL).", + "Insulin levels were 1.05 μIU/mL.", + "C-peptide levels were 0.71 ng/ml.", + "IGF1 levels were 39 ng/mL.", + "Western blot analysis of the patient’s serum revealed overexpression of high-molecular-weight IGF-2 designated 'big IGF-2'.", + "The patient underwent surgery for total tumor resection.", + "In the operative view, the large tumor appeared to compress the right lobe of the liver without invasion.", + "The feeding artery originating from the diaphragm was ligated and divided.", + "A part of the diaphragm was resected with autosuture owing to firm adherence of the diaphragm to the artery.", + "The tumor was dissected along the liver surface without simultaneous resection of any other organs.", + "A tumor-free margin was achieved macroscopically.", + "The tumor measured 34 cm at the major axis and weighed 1350 g.", + "The tumor was well demarcated by a fibrous membrane.", + "The resected surface was elastic, firm, had an ivory-like appearance, and was multilobulated with trabeculation.", + "The solid component was predominant, and a small myxoid component was also noted.", + "Microscopically, spindle cells generally constituted the tumor without specific cellular arrangement in the solid component.", + "A few areas in this component demonstrated keloid-like collagenous stroma and stag horn-like vessels.", + "Some areas with myxoid appearance upon gross examination revealed a multi-cystic formation by cavernous hemangioma-like septa.", + "Karyokinesis was detected in more than 0/10 high-power fields in the hypercellular area.", + "Necrosis was obscure.", + "Immunohistochemically, the tumor cells expressed STAT6 and CD34.", + "The highest Ki-67 labeling index was 15%.", + "These results confirmed that the tumor was a malignant SFT.", + "The tumor cells exhibited cytoplasmic IGF2 expression, specifically with paranuclear dot-like reactivity.", + "The tumor cells were positive for IGF2R but negative for IGF1R.", + "Since surgery, the patient has been free from tumor recurrence and hypoglycemia for more than 24 months." + ], + "summary": "An 81-year-old man with a large subphrenic mass presented with hypoglycemia and loss of consciousness. His serum insulin and IGF1 levels were relatively low, suggesting an excessively high serum IGF2 levels. Preoperative Western blotting of serum confirmed the overproduction of high-molecular-weight IGF2. After total tumor resection, the patient recovered from hypoglycemia without the need for further treatment. Histological examination revealed proliferation of spindle cells and frequent nuclear mitoses with STAT6 and CD34 immunoreactivity, which led to the diagnosis of malignant SFT. IGF2 was strongly upregulated in the tumor upon immunohistochemistry, consistent with the report of NICTH. In addition, the tumor expressed IGF2 receptor (IGF2R) but not IGF1R.", + "summary_subclaims": [ + "An 81-year-old man with a large subphrenic mass presented with hypoglycemia and loss of consciousness.", + "His serum insulin and IGF1 levels were relatively low, suggesting an excessively high serum IGF2 levels.", + "Preoperative Western blotting of serum confirmed the overproduction of high-molecular-weight IGF2.", + "After total tumor resection, the patient recovered from hypoglycemia without the need for further treatment.", + "Histological examination revealed proliferation of spindle cells and frequent nuclear mitoses with STAT6 and CD34 immunoreactivity.", + "The diagnosis was malignant SFT.", + "IGF2 was strongly upregulated in the tumor upon immunohistochemistry.", + "The tumor expressed IGF2 receptor (IGF2R) but not IGF1R." + ] + }, + { + "id": "multiclinsum_test_3317_en.txt", + "fulltext": "We describe the case of a 63-year-old man, Caucasian, affected by non-ischemic dilated cardiomyopathy who did not drink alcohol, did not smoke tobacco, and did not have diabetes. He had an implantable cardioverter defibrillator implanted, in New York Heart Association (NYHA) IV class, and left bundle branch block (LBBB; QRS duration of 145 ms). He was referred for CRT-D upgrade, awaiting cardiac transplantation, despite optimal medical therapy: b-Blockade, loop-diuretic, angiotensin-converting enzyme (ACE) inhibitor, K-sparing agent, and ivabradine. Standard clinical imaging protocol revealed a dilated left ventricle with an end-systolic volume (ESV) of 380 ml, an ejection fraction (EF) of 4.8% as measured by the modified Simpson’s method, and severe FMR, assessed by qualitative estimation with two-dimensional color flow Doppler approach, showing a very large central jet and reaching the posterior wall of the left atrium.\n\nHe underwent the implant of a CRT-D device with a quadripolar left ventricular (LV) lead placed in the posterolateral branch of the coronary sinus. After recording the right ventricle (RV)-to-LV electrical delay at each of the four LV rings, we chose the A1 unipolar vector for LV pacing (greatest electrical delay 80 ms).\n\nAt 13-day post-implant follow-up, he showed worsening heart failure (HF) symptoms and only A2 unipolar LV vector configuration, with interventricular (VV) interval of 0 ms, was suitable for simultaneous biventricular activation.\n\nEcho-PIV was then used, during the acute study with contrast agent bubbles, to evaluate the orientation and relative magnitude of blood-induced intraventricular forces in correspondence of different pacing settings.\n\nWithout pacing stimulation (CRT OFF) the intraventricular flow was dominated by rotation without evident inflow–outflow dynamics. As a result the intraventricular forces were predominantly transverse and not aligned along the LV axis as quantified by the large value of their mean angle φ (φ = 55.6°, this angle ranges from 0°, when forces are aligned with the LV axis, to 90°). A first setting option (CRT ON, VV delay 0 ms) changed the orientation of intraventricular forces reducing the angle (φ = 45°), and increasing the delay (CRT ON, VV delay − 30 ms) improved the alignment reducing the angle (φ = 40.3°). Eventually, the sequential biventricular activation with delay − 50 ms provided the best alignment of intraventricular forces (φ = 38.8°).\n\nNo reduction of FMR by three-dimensional FVCD, during the same acute study with shutdown versus reactivation of device.\n\nThe data acquisition time, by three-chamber apical view, for each three-dimensional color Doppler data set was approximately 5 seconds, and it took less than 3 minutes to analyze the average regurgitation volume, with automated anatomy detection of the LV endocardial border, mitral annulus (MA), LV outflow (LVOT), and placement of three-dimensional hemispheric flow sampling planes in the MA and LVOT. The software of three-dimensional FVCD computed the flow volumes as the area under the curve of both the MA and LVOT flow in three cardiac cycles, and FMR volume was calculated by subtracting LVOT stroke volume from MA stroke volume.\n\nResults at 6-month follow-up\n\nOur patient showed an improvement of NYHA class (III versus IV) and LV EF (26.6% versus 4.8%). Significant reduction of ESV (288 ml versus 380 ml) and persistent improvement of diastolic function were obtained. The regularized function is noticeable. At follow-up, a significant reduction of FMR (mean value regurgitant volume, 42.2 ml versus 65.3 ml) was estimated.\n\nThe intraventricular forces estimated by echo-PIV were still partially dominated by the longitudinal path of pressure gradient with φ = 43.1°.", + "fulltext_subclaims": [ + "The patient is a 63-year-old man.", + "The patient is Caucasian.", + "The patient has non-ischemic dilated cardiomyopathy.", + "The patient did not drink alcohol.", + "The patient did not smoke tobacco.", + "The patient did not have diabetes.", + "The patient had an implantable cardioverter defibrillator implanted.", + "The patient was in New York Heart Association (NYHA) IV class.", + "The patient had left bundle branch block (LBBB; QRS duration of 145 ms).", + "The patient was referred for CRT-D upgrade.", + "The patient was awaiting cardiac transplantation.", + "The patient was receiving optimal medical therapy.", + "The patient was receiving b-Blockade.", + "The patient was receiving loop-diuretic.", + "The patient was receiving angiotensin-converting enzyme (ACE) inhibitor.", + "The patient was receiving K-sparing agent.", + "The patient was receiving ivabradine.", + "Standard clinical imaging protocol revealed a dilated left ventricle.", + "The end-systolic volume (ESV) was 380 ml.", + "The ejection fraction (EF) was 4.8% as measured by the modified Simpson’s method.", + "Severe functional mitral regurgitation (FMR) was assessed by qualitative estimation with two-dimensional color flow Doppler approach.", + "The FMR showed a very large central jet.", + "The FMR jet reached the posterior wall of the left atrium.", + "The patient underwent the implant of a CRT-D device.", + "A quadripolar left ventricular (LV) lead was placed in the posterolateral branch of the coronary sinus.", + "The right ventricle (RV)-to-LV electrical delay was recorded at each of the four LV rings.", + "The A1 unipolar vector was chosen for LV pacing.", + "The greatest electrical delay was 80 ms.", + "At 13-day post-implant follow-up, the patient showed worsening heart failure (HF) symptoms.", + "Only A2 unipolar LV vector configuration was suitable for simultaneous biventricular activation.", + "The interventricular (VV) interval was 0 ms.", + "Echo-PIV was used during the acute study with contrast agent bubbles.", + "Echo-PIV evaluated the orientation and relative magnitude of blood-induced intraventricular forces.", + "Without pacing stimulation (CRT OFF), the intraventricular flow was dominated by rotation.", + "The intraventricular forces were predominantly transverse.", + "The mean angle φ was 55.6°.", + "A first setting option (CRT ON, VV delay 0 ms) changed the orientation of intraventricular forces.", + "The angle φ was reduced to 45°.", + "Increasing the delay (CRT ON, VV delay − 30 ms) improved the alignment.", + "The angle φ was reduced to 40.3°.", + "Sequential biventricular activation with delay − 50 ms provided the best alignment.", + "The angle φ was 38.8°.", + "No reduction of FMR by three-dimensional FVCD was observed.", + "The data acquisition time for each three-dimensional color Doppler data set was approximately 5 seconds.", + "The analysis of average regurgitation volume took less than 3 minutes.", + "Automated anatomy detection of the LV endocardial border, mitral annulus (MA), LV outflow (LVOT), and placement of three-dimensional hemispheric flow sampling planes in the MA and LVOT was performed.", + "The software of three-dimensional FVCD computed the flow volumes as the area under the curve of both the MA and LVOT flow in three cardiac cycles.", + "FMR volume was calculated by subtracting LVOT stroke volume from MA stroke volume.", + "At 6-month follow-up, the patient showed an improvement of NYHA class to III.", + "The LV EF improved to 26.6%.", + "The ESV was reduced to 288 ml.", + "Persistent improvement of diastolic function was obtained.", + "A significant reduction of FMR (mean value regurgitant volume, 42.2 ml) was estimated.", + "The intraventricular forces estimated by echo-PIV were still partially dominated by the longitudinal path of pressure gradient.", + "The mean angle φ was 43.1°." + ], + "summary": "We describe a case in which the two technologies are used in combination during acute echocardiographic optimization of left pacing vector in a 63-year-old man, Caucasian, who showed worsening heart failure symptoms a few days after an implant, and the effect of the device’s optimization at 6-month follow-up.", + "summary_subclaims": [ + "The patient is a 63-year-old man.", + "The patient is Caucasian.", + "The patient showed worsening heart failure symptoms a few days after an implant.", + "The two technologies are used in combination during acute echocardiographic optimization of left pacing vector.", + "The effect of the device’s optimization is assessed at 6-month follow-up." + ] + }, + { + "id": "multiclinsum_test_2740_en.txt", + "fulltext": "This is the case of a 13-year-old black African boy of the Bantu ethnic group, a student, who presented at the pediatric emergency room of Yaounde University Hospital Center with intense chest and vertebral pains, evolving for 48 hours before admission. A week before, in the course of a brawl his left forearm was twisted, resulting in a sharp and permanent pain in his left forearm associated with a functional impotence without any cutaneous lesions. At home, his tutor gave him paracetamol and diclofenac that were administered orally followed by a consultation the next day at a traditional healer. The traditional healer carried out scarifications on our patient’s forearm, consisting of multiple superficial incisions of the skin made by a blade, supplemented by the application on the cutaneous lesions of an ointment composed of herbs, leaves, and earth, which would be likely to contain Clostridium tetani spores. Less than 48 hours later, there was an onset of a generalized pain, predominant in our patient’s back and in his sternal region.\nThe adolescent lives with his aunt in town. There were no elements in favor of a non-accidental injury or child abuse. He had no history of chronic disease; he has never had an operation. The immunization status of the child was unknown to the next of kin.\nOn general examination on his presentation to our emergency department, he was conscious and ill-looking. His temperature ranged between 36.8 and 38.3 °C, his pulse was 88 beats per minute, his pupils were equal and reactive to light stimulus, and his blood pressure was 105/70 mmHg. He presented a trismus, spinal stiffness, a generalized contracture with abdominal rigidity, and opisthotonus. In addition, there were also spasms triggered by noise, light, and touch during care.\nThe loco-regional examination of his left upper limb revealed a balm based on herbs and black earth placed under a traditional splint. After removal of the latter, scarifications were visible with areas of cutaneous necrosis . The rest of the examination was otherwise normal.\nAn X-ray of his left forearm showed a slightly displaced shaft fracture of the two bones of his forearm classified Orthopaedic Trauma Association (OTA)/AO 22-A3 . His hematological and blood electrolytes profiles were within normal limits. No biologic test was performed for the detection of tetanus antitoxin antibodies in whole blood due to the non-availability of this test in our setting at the time.\nThe diagnosis of generalized tetanus complicating a closed fracture of the forearm with subsequent opening was made. Generalized tetanus was thus diagnosed a few hours after our patient’s admission on the basis of the clinical examination in particular, and an obvious point of entry in an individual with unknown vaccination status who clinically presented a trismus, a generalized contracture, as well as paroxysms.\nHe was subsequently admitted 6 hours later to our intensive care unit. He was placed in solitary confinement in a dimly lit room; a nasogastric tube was placed, and sedation and diazepam myorelaxation were performed. The etiological treatment consisted of an antibiotherapy based on metronidazole that was intravenously, directly, and slowly administered and an immunotherapy with equine anti-tetanus serum. Subsequent disinfection of the point of entry with resection of necrotic tissue was performed to reduce microbial growth and release of toxins.\nThe evolution was marked by a gradual deterioration in his state of consciousness, dysautonomic manifestations, particularly blood pressure surges, and tachycardia alternating with bradycardia. Moreover, the occurrence of several episodes of tonic–clonic paroxysms required additional doses of muscle relaxant and intubation. He died a few hours later in our intensive care unit, 12 hours after admission to our hospital.", + "fulltext_subclaims": [ + "The patient is a 13-year-old black African boy of the Bantu ethnic group.", + "He presented at the pediatric emergency room of Yaounde University Hospital Center with intense chest and vertebral pains.", + "The pains had been evolving for 48 hours before admission.", + "A week before, in the course of a brawl, his left forearm was twisted.", + "This resulted in a sharp and permanent pain in his left forearm.", + "There was a functional impotence without any cutaneous lesions.", + "At home, his tutor gave him paracetamol and diclofenac that were administered orally.", + "He had a consultation the next day at a traditional healer.", + "The traditional healer carried out scarifications on the patient’s forearm.", + "The scarifications consisted of multiple superficial incisions of the skin made by a blade.", + "An ointment composed of herbs, leaves, and earth was applied on the cutaneous lesions.", + "The ointment was likely to contain Clostridium tetani spores.", + "Less than 48 hours later, there was an onset of a generalized pain.", + "The generalized pain was predominant in the patient’s back and in his sternal region.", + "The patient lives with his aunt in town.", + "There were no elements in favor of a non-accidental injury or child abuse.", + "He had no history of chronic disease.", + "He has never had an operation.", + "The immunization status of the child was unknown to the next of kin.", + "On general examination, he was conscious and ill-looking.", + "His temperature ranged between 36.8 and 38.3 °C.", + "His pulse was 88 beats per minute.", + "His pupils were equal and reactive to light stimulus.", + "His blood pressure was 105/70 mmHg.", + "He presented a trismus.", + "He had spinal stiffness.", + "He had a generalized contracture with abdominal rigidity.", + "He had opisthotonus.", + "There were spasms triggered by noise, light, and touch during care.", + "The loco-regional examination of his left upper limb revealed a balm based on herbs and black earth.", + "The balm was placed under a traditional splint.", + "After removal of the splint, scarifications were visible with areas of cutaneous necrosis.", + "An X-ray of his left forearm showed a slightly displaced shaft fracture of the two bones of his forearm.", + "The fracture was classified Orthopaedic Trauma Association (OTA)/AO 22-A3.", + "His hematological and blood electrolytes profiles were within normal limits.", + "No biologic test was performed for the detection of tetanus antitoxin antibodies in whole blood.", + "The test was not available in their setting at the time.", + "The diagnosis of generalized tetanus complicating a closed fracture of the forearm with subsequent opening was made.", + "Generalized tetanus was diagnosed a few hours after admission.", + "The diagnosis was based on clinical examination.", + "There was an obvious point of entry in an individual with unknown vaccination status.", + "The patient clinically presented a trismus.", + "He had a generalized contracture.", + "He had paroxysms.", + "He was admitted to the intensive care unit 6 hours later.", + "He was placed in solitary confinement in a dimly lit room.", + "A nasogastric tube was placed.", + "Sedation and diazepam myorelaxation were performed.", + "The etiological treatment consisted of an antibiotherapy based on metronidazole.", + "The metronidazole was intravenously, directly, and slowly administered.", + "Immunotherapy with equine anti-tetanus serum was performed.", + "Subsequent disinfection of the point of entry with resection of necrotic tissue was performed.", + "The evolution was marked by a gradual deterioration in his state of consciousness.", + "There were dysautonomic manifestations, particularly blood pressure surges.", + "There were episodes of tachycardia alternating with bradycardia.", + "Several episodes of tonic–clonic paroxysms occurred.", + "Additional doses of muscle relaxant were required.", + "Intubation was performed.", + "He died a few hours later in the intensive care unit.", + "He died 12 hours after admission to the hospital." + ], + "summary": "A 13-year-old black African boy of the Bantu ethnic group with unknown tetanus vaccination status presented to our pediatric emergency room for the management of chest and vertebral pains which started a few days after traditional treatment by scarification and herbal and leaf ointment. The treatment was initiated by a traditional healer and indicated for a closed fracture of our patient's left forearm sustained during a fight. The diagnosis of generalized tetanus was made on the basis of generalized contractures with opisthotonus, trismus, and autonomic nervous system dysfunction. Despite prompt intensive care management, he died a few hours after admission.", + "summary_subclaims": [ + "The patient is a 13-year-old black African boy of the Bantu ethnic group.", + "The patient had unknown tetanus vaccination status.", + "The patient presented to the pediatric emergency room for management of chest and vertebral pains.", + "The chest and vertebral pains started a few days after traditional treatment.", + "The traditional treatment included scarification and herbal and leaf ointment.", + "The traditional treatment was initiated by a traditional healer.", + "The traditional treatment was indicated for a closed fracture of the patient's left forearm.", + "The closed fracture was sustained during a fight.", + "The diagnosis of generalized tetanus was made.", + "The diagnosis was based on generalized contractures with opisthotonus, trismus, and autonomic nervous system dysfunction.", + "The patient died a few hours after admission." + ] + }, + { + "id": "multiclinsum_test_1834_en.txt", + "fulltext": "A 67-year-old male presented with abdominal pain and blood-tinged stool of 1-month's duration. His past medical history revealed hypertension well controlled by medication for 8 years and that he had been a smoker for 20 pack years. His family history was noncontributory. Physical examination revealed a protuberant abdomen with a huge tender intra-abdominal mass. Laboratory findings including blood analysis, serum electrolytes, and hepatic and renal functions were within normal limits, as was the serum alkaline phosphatase.\nOn colonoscopy, a solid mass measuring 5 cm was detected protruding from the colon wall . The mass was covered with blood clots and necrotic debris. Colonoscopic biopsy confirmed a sarcoma of an undetermined type. Computed tomography demonstrated a 15 × 9.7 cm heterogeneously enhancing mass, with mottled calcification and a cystic portion, occupying the left upper quadrant of the abdominal cavity . For curative resection of the tumor, en bloc mass excision with segmental colon resection and splenectomy was performed. During the operation, the surgeon described the tumor as being located in the mesentery and involving the stomach, greater omentum, pancreas, and transverse colon. The resected tumor measured 18.5 × 13 × 9.5 cm. It was located in the mesentery and perforated the abutting colon wall. The external surface of the mass was smooth. The cut surface consisted of a gray-white to tan-yellow solid area with a gritty sensation and a large multicystic area . The cystic portion contained clotted blood with thin septae and was focally necrotic.\nSections taken from the cystic structure showed large blood-filled spaces separated by thin septae and smaller cystic spaces within the solid area. The septal walls consisted of numerous large, bizarre rounded to spindled cells with multilobed hyperchromatic nuclei, and coarse granular chromatin . Sections from the firm, calcified portion revealed a poorly differentiated sarcomatous tumor showing a solid growth pattern with large anaplastic cells and spindle cells . Giant cells with multiple bizarre nuclei or osteoclast-like giant cells were scattered throughout the tumor and were associated with the areas of hemorrhage. The osteoid was laid down in a fine ramifying lacework, and was partly calcified . Transition areas between neoplastic osteoid and cartilage were noted . More than 20 mitoses per ten high-power fields were observed, and these included highly atypical forms. Necrosis was evident.\nFor immunohistochemical studies, paraffin-embedded tissue was stained using the avidin-biotin peroxidase complex method. The neoplastic cells were positive for vimentin, alpha smooth muscle actin, osteonectin, CD99, and S100 in the chondroblastic portion, but negative for cytokeratin, epithelial membrane antigen, desmin, myogenin, CD34, and c-kit. The final histologic diagnosis was a mesenteric extraskeletal osteosarcoma with telangiectatic features.\nAfter the uneventful surgery, the patient underwent the first cycle of chemotherapy consisting of intravenous ifosfamide (1800 mg/m2) and adriamycin (25 mg/m2). However, he developed a recurrent peritoneal mass measuring 11 × 9.5 cm and multiple lung and liver metastases 3 months postoperatively. He died 4 months later.", + "fulltext_subclaims": [ + "The patient was a 67-year-old male.", + "He presented with abdominal pain and blood-tinged stool of 1-month's duration.", + "His past medical history included hypertension well controlled by medication for 8 years.", + "He had been a smoker for 20 pack years.", + "Physical examination revealed a protuberant abdomen with a huge tender intra-abdominal mass.", + "Laboratory findings including blood analysis, serum electrolytes, and hepatic and renal functions were within normal limits.", + "The serum alkaline phosphatase was within normal limits.", + "On colonoscopy, a solid mass measuring 5 cm was detected protruding from the colon wall.", + "The mass was covered with blood clots and necrotic debris.", + "Colonoscopic biopsy confirmed a sarcoma of an undetermined type.", + "Computed tomography demonstrated a 15 × 9.7 cm heterogeneously enhancing mass.", + "The mass occupied the left upper quadrant of the abdominal cavity.", + "For curative resection of the tumor, en bloc mass excision with segmental colon resection and splenectomy was performed.", + "The surgeon described the tumor as being located in the mesentery and involving the stomach, greater omentum, pancreas, and transverse colon.", + "The resected tumor measured 18.5 × 13 × 9.5 cm.", + "The tumor was located in the mesentery and perforated the abutting colon wall.", + "The external surface of the mass was smooth.", + "The cut surface consisted of a gray-white to tan-yellow solid area with a gritty sensation and a large multicystic area.", + "The cystic portion contained clotted blood with thin septae and was focally necrotic.", + "Sections taken from the cystic structure showed large blood-filled spaces separated by thin septae and smaller cystic spaces within the solid area.", + "The septal walls consisted of numerous large, bizarre rounded to spindled cells with multilobed hyperchromatic nuclei, and coarse granular chromatin.", + "Sections from the firm, calcified portion revealed a poorly differentiated sarcomatous tumor showing a solid growth pattern with large anaplastic cells and spindle cells.", + "Giant cells with multiple bizarre nuclei or osteoclast-like giant cells were scattered throughout the tumor and were associated with the areas of hemorrhage.", + "The osteoid was laid down in a fine ramifying lacework, and was partly calcified.", + "Transition areas between neoplastic osteoid and cartilage were noted.", + "More than 20 mitoses per ten high-power fields were observed, and these included highly atypical forms.", + "Necrosis was evident.", + "For immunohistochemical studies, paraffin-embedded tissue was stained using the avidin-biotin peroxidase complex method.", + "The neoplastic cells were positive for vimentin, alpha smooth muscle actin, osteonectin, CD99, and S100 in the chondroblastic portion.", + "The neoplastic cells were negative for cytokeratin, epithelial membrane antigen, desmin, myogenin, CD34, and c-kit.", + "The final histologic diagnosis was a mesenteric extraskeletal osteosarcoma with telangiectatic features.", + "The patient underwent the first cycle of chemotherapy consisting of intravenous ifosfamide (1800 mg/m2) and adriamycin (25 mg/m2).", + "He developed a recurrent peritoneal mass measuring 11 × 9.5 cm and multiple lung and liver metastases 3 months postoperatively.", + "He died 4 months later." + ], + "summary": "A 67-year-old male presented with blood-tinged stool of 1-month's duration. On colonoscopy, a solid mass was detected protruding from the colon wall. Computed tomography showed a 15 x 9.7 cm heterogeneously enhancing mass, with mottled calcification and a cystic portion, occupying the left upper quadrant of the abdominal cavity. Curative resection of the tumor was performed, and the excised tumor was composed of large multilocular cysts containing old hematomas and necrotic debris. The histology revealed an osteosarcoma showing osteoid formation and blood-filled spaces lined with atypical cells. Despite postoperative chemotherapy, he developed a recurrent peritoneal mass and multiple lung metastases 3 months postoperatively.", + "summary_subclaims": [ + "The patient is a 67-year-old male.", + "He presented with blood-tinged stool of 1-month's duration.", + "On colonoscopy, a solid mass was detected protruding from the colon wall.", + "Computed tomography showed a 15 x 9.7 cm heterogeneously enhancing mass.", + "The mass had mottled calcification.", + "The mass had a cystic portion.", + "The mass occupied the left upper quadrant of the abdominal cavity.", + "Curative resection of the tumor was performed.", + "The excised tumor was composed of large multilocular cysts.", + "The cysts contained old hematomas.", + "The cysts contained necrotic debris.", + "The histology revealed an osteosarcoma.", + "The osteosarcoma showed osteoid formation.", + "The osteosarcoma had blood-filled spaces lined with atypical cells.", + "Postoperative chemotherapy was administered.", + "He developed a recurrent peritoneal mass 3 months postoperatively.", + "He developed multiple lung metastases 3 months postoperatively." + ] + }, + { + "id": "multiclinsum_test_3196_en.txt", + "fulltext": "After experiencing constipation and abdominal distension for three days, a 55-year-old man was brought to the emergency department for treatment. The patient had a fever following an upper respiratory illness 9 days before admission. He had neither a history of anticholinergic prescription use nor recent abdominal surgery. His vital signs upon arrival were as follows: His temperature was 37.8°C, his pulse rate was 92 beats per minute, his respiratory rate was 20 breaths per minute, and his blood pressure was recorded at 151/99 mmHg upon arrival. He had a swollen, non-tender, tympanitic belly and no audible bowel sounds during auscultation. Hepatosplenomegaly or peritoneal irritation signs were absent in the patient. Urinary retention was not noticed. Abdominal ultrasound revealed diffuse abdominal gas distention and a dilated small intestine. On auscultation, active peristalsis was absent.\n\nThree days after abdominal distension, the patient developed ascending weakness in both upper and lower extremities. A neurological evaluation revealed sensory deficiencies (reduced sensation to touch and reduced sensitivity to pain, while vibration and joint position sense was intact) and decreased muscle strength (3/5 both upper and lower extremities based on the MRC scale). The patients’ s deep tendon reflexes were absent in both upper and lower extremities. Plantar reflexes were muted bilaterally. His initial bowel distension was not considered a neurological manifestation; however, the development of symmetrical quadriparesis caught the neurologist’s attention.\n\nRoutine biochemical studies, including serum potassium level (4 mEq/L) and other blood tests, showed no abnormal findings. Magnetic resonance imaging of the brain, cervical, and thoracic spinal cord did not reveal any underlying brain or spinal pathology. Abdominal CT with contrast showed markedly delayed bowel without mechanical obstruction, which suggested paralytic ileus, and no contrast passed through the duodenum during a 6-hour small bowel series examination. Over the next few days of total parenteral feeding and prokinetic use (metoclopramide 10 mg IV TID), the patient showed persistent severe ileus. A nerve conduction study (done 4 days of symptom onset) demonstrated demyelinating sensorimotor polyneuropathy. Cerebrospinal fluid analysis showed a normal white blood cell count (2 WBC/μL), high protein (819.9 mg/L; reference: 150–450 mg/L), and a glucose level of 55 mg/dl. This showed albumin-cytological dissociation. Based on the clinical presentation, neurophysiologic findings, and CSF findings, we diagnosed him with Guillain-Barre syndrome. Immediate treatment with intravenous immunoglobulin (IVIG) 0.4 g/kg daily for 5 days was initiated. Five days after the onset of motor weakness, the patient’s condition rapidly progressed to involve bilateral facial paralysis (facial diplegia) and dysphagia. In the next few days, the patient developed respiratory failure requiring mechanical ventilation due to diaphragmatic weakness. The patient was transferred to the intensive care unit. After 2 months of intubation in the intensive care unit, the patient passed away due to septicemia. In this case, the patient presented with paralytic ileus as a type of dysautonomia; however, it was not recognized as GBS dysautonomia. The later emergence of motor weakness and sensory disturbances prompted the consideration of GBS.", + "fulltext_subclaims": [ + "A 55-year-old man was brought to the emergency department after experiencing constipation and abdominal distension for three days.", + "The patient had a fever following an upper respiratory illness 9 days before admission.", + "The patient had neither a history of anticholinergic prescription use nor recent abdominal surgery.", + "His temperature upon arrival was 37.8°C.", + "His pulse rate upon arrival was 92 beats per minute.", + "His blood pressure upon arrival was 151/99 mmHg.", + "He had a swollen, non-tender, tympanitic belly.", + "No audible bowel sounds were heard during auscultation.", + "Hepatosplenomegaly or peritoneal irritation signs were absent.", + "Urinary retention was not noticed.", + "Abdominal ultrasound revealed diffuse abdominal gas distention.", + "Abdominal ultrasound showed a dilated small intestine.", + "On auscultation, active peristalsis was absent.", + "Three days after abdominal distension, the patient developed ascending weakness in both upper and lower extremities.", + "A neurological evaluation revealed reduced sensation to touch.", + "A neurological evaluation revealed reduced sensitivity to pain.", + "A neurological evaluation revealed intact vibration and joint position sense.", + "Muscle strength was 3/5 in both upper and lower extremities based on the MRC scale.", + "Deep tendon reflexes were absent in both upper and lower extremities.", + "Plantar reflexes were muted bilaterally.", + "The initial bowel distension was not considered a neurological manifestation.", + "The development of symmetrical quadriparesis caught the neurologist’s attention.", + "Routine biochemical studies showed no abnormal findings.", + "Magnetic resonance imaging of the brain, cervical, and thoracic spinal cord did not reveal any underlying brain or spinal pathology.", + "Abdominal CT with contrast showed markedly delayed bowel without mechanical obstruction.", + "The abdominal CT suggested paralytic ileus.", + "No contrast passed through the duodenum during a 6-hour small bowel series examination.", + "The patient showed persistent severe ileus over the next few days of total parenteral feeding and prokinetic use.", + "A nerve conduction study demonstrated demyelinating sensorimotor polyneuropathy.", + "Cerebrospinal fluid analysis showed a normal white blood cell count (2 WBC/μL).", + "Cerebrospinal fluid analysis showed high protein (819.9 mg/L).", + "Cerebrospinal fluid analysis showed a glucose level of 55 mg/dl.", + "The CSF findings showed albumin-cytological dissociation.", + "Based on the clinical presentation, neurophysiologic findings, and CSF findings, we diagnosed him with Guillain-Barre syndrome.", + "Immediate treatment with intravenous immunoglobulin (IVIG) 0.4 g/kg daily for 5 days was initiated.", + "Five days after the onset of motor weakness, the patient developed bilateral facial paralysis.", + "Five days after the onset of motor weakness, the patient developed dysphagia.", + "The patient developed respiratory failure requiring mechanical ventilation due to diaphragmatic weakness.", + "The patient was transferred to the intensive care unit.", + "After 2 months of intubation in the intensive care unit, the patient passed away due to septicemia.", + "In this case, the patient presented with paralytic ileus as a type of dysautonomia.", + "The paralytic ileus was not recognized as GBS dysautonomia.", + "The later emergence of motor weakness and sensory disturbances prompted the consideration of GBS." + ], + "summary": "Here we describe the case of a 55-year-old man who was brought to the emergency room of our hospital with paralytic ileus, a less common symptom of early-stage GBS. The patient was initially treated with prokinetic drugs and total parenteral nutrition with no clinical improvement. The patient quickly developed ascending lower limb weakness that progressed to quadriplegia, which ultimately affected respiratory muscles, leading to respiratory failure requiring mechanical ventilation and intensive care unit hospitalization. A nerve conduction study showed demyelinating sensorimotor polyneuropathy. Analysis of cerebrospinal fluid revealed albumin-cytological dissociation. The patient was treated with intravenous immunoglobulin (IVIG) and other supportive treatments. Even though the patient's enteral feeding support was uncomfortable due to a profound infection complicating lack of stomach emptying during the hospital stay, the patient passed away two months after being admitted.", + "summary_subclaims": [ + "The patient was a 55-year-old man.", + "The patient was brought to the emergency room with paralytic ileus.", + "Paralytic ileus was a less common symptom of early-stage GBS.", + "The patient was initially treated with prokinetic drugs.", + "The patient was initially treated with total parenteral nutrition.", + "The patient had no clinical improvement.", + "The patient quickly developed ascending lower limb weakness.", + "The weakness progressed to quadriplegia.", + "The weakness affected respiratory muscles.", + "The patient developed respiratory failure.", + "The patient required mechanical ventilation.", + "The patient was hospitalized in the intensive care unit.", + "A nerve conduction study showed demyelinating sensorimotor polyneuropathy.", + "Analysis of cerebrospinal fluid revealed albumin-cytological dissociation.", + "The patient was treated with intravenous immunoglobulin (IVIG).", + "The patient received other supportive treatments.", + "The patient's enteral feeding support was uncomfortable.", + "The patient had a profound infection.", + "The infection complicated lack of stomach emptying.", + "The patient passed away two months after being admitted." + ] + }, + { + "id": "multiclinsum_test_2954_en.txt", + "fulltext": "A 22-year-old Caucasian male was admitted to hospital with aggravated signs of anaemia: primarily exhaustion and sleepiness, accompanied by marked pallor. Iron deficiency anaemia had been diagnosed in this patient at the age of 2 months. The patient was then put on iron supplements along with other vitamins necessary for erythropoiesis. Before his first birthday, celiac disease was histologically diagnosed, and anaemia was considered to be an accompanying disease. In early childhood, the patient experienced a cytomegalovirus infection as well as other typical childhood diseases. He was immunized according to his home country’s specific vaccination schedule and had an otherwise unremarkable childhood. Even though the patient had been put on oral iron and vitamin supplements, the severity of the anaemia remained within the moderate to severe range, only sporadically mild, and therefore the patient underwent further testing. At the age of 18, the patient underwent bone marrow examination with no pathologic findings, as well as an upper gastrointestinal endoscopy, lower gastrointestinal endoscopy, and capsule endoscopy, all of which had done previously. This time, however, the discovery of dilated blood vessels in the duodenum was made during upper gastrointestinal endoscopy, although neither angiodysplasia nor Osler-Weber-Rendu disease were found. A computed tomography (CT) of the abdomen was performed resulting in the discovery of an intestinal malrotation of the duodenum and an absence of the proximal part of the SMV with varices in the duodenal wall, which had functioned as a collateral blood flow due to mesenteric vein occlusion . The anaemia was proclaimed to be a result of chronic occult blood loss through dilated blood vessels in duodenal mucosa, and therapy slightly helped the condition at the time.\nAt the age of 22, the patient quit taking all supplements. The resulting life-threatening anaemia necessitated hospitalization and red blood cell transfusions within 6 months. Although, the transfusions did not yield the expected results, they indirectly confirmed a chronic loss via the duodenal collaterals. The patient underwent another computed tomography of the abdomen which confirmed the previous findings, and, after his condition was stabilized, was referred to our surgical clinic for a consultation. An elective surgery was scheduled for the following month. Meanwhile, the patient was treated with repeated intravenous iron supplementation and correction of hemostasis parameters. Finally, when the patient was admitted to our surgical ward, he was slightly pale but a physical examination produced no remarkable findings. The next day, he underwent surgery under general anaesthesia with mobilisation of the malrotated bowel, and after meticulous preparation we were able to find the suitable blood vessels for the bypass. After administering an intravenous heparin (100 units per kg), we created an anastomosis between the large collateral arising from the distal section of the SMV and the anterior inferior pancreaticoduodenal vein draining to the present proximal section of the SMV without any prosthetic material . We also performed ligation of some dilated veins on the duodenal surface with the aim to interrupt the blood flow in the duodenal varices. The postoperative period was unremarkable, and the patient was discharged to outpatient care. During the 3-month period after the surgery, we put the patient on anticoagulant treatment with low molecular weight heparins. Five months after the surgical intervention, a CT of the abdomen was performed to confirm the patency of the venous anastomosis and diminution of duodenal varices. A slightly stenotic passage through the anastomosis with a regression of the duodenal varices, draining into the SMV, was observed. Two months later, the patient underwent an upper gastrointestinal endoscopy with the intention to ligate the residual duodenal varices. The patient still has three large duodenal varices, which have been currently left untreated because of the patient’s good clinical and laboratory status with no clinical signs of bleeding and no anaemia or iron deficiency.", + "fulltext_subclaims": [ + "The patient is a 22-year-old Caucasian male.", + "The patient was admitted to hospital with aggravated signs of anaemia.", + "The signs of anaemia included exhaustion and sleepiness.", + "The signs of anaemia were accompanied by marked pallor.", + "Iron deficiency anaemia had been diagnosed in this patient at the age of 2 months.", + "The patient was put on iron supplements along with other vitamins necessary for erythropoiesis.", + "Celiac disease was histologically diagnosed before the patient's first birthday.", + "Anaemia was considered to be an accompanying disease.", + "The patient experienced a cytomegalovirus infection in early childhood.", + "The patient was immunized according to his home country’s specific vaccination schedule.", + "The patient had an otherwise unremarkable childhood.", + "The severity of the anaemia remained within the moderate to severe range.", + "The patient underwent further testing.", + "At the age of 18, the patient underwent bone marrow examination with no pathologic findings.", + "At the age of 18, the patient underwent an upper gastrointestinal endoscopy.", + "At the age of 18, the patient underwent a lower gastrointestinal endoscopy.", + "At the age of 18, the patient underwent capsule endoscopy.", + "During upper gastrointestinal endoscopy, dilated blood vessels in the duodenum were discovered.", + "Angiodysplasia was not found.", + "Osler-Weber-Rendu disease was not found.", + "A computed tomography (CT) of the abdomen was performed.", + "The CT discovered an intestinal malrotation of the duodenum.", + "The CT discovered an absence of the proximal part of the SMV.", + "The CT discovered varices in the duodenal wall.", + "The varices had functioned as a collateral blood flow due to mesenteric vein occlusion.", + "The anaemia was proclaimed to be a result of chronic occult blood loss through dilated blood vessels in duodenal mucosa.", + "Therapy slightly helped the condition at the time.", + "At the age of 22, the patient quit taking all supplements.", + "The resulting life-threatening anaemia necessitated hospitalization.", + "Red blood cell transfusions were given within 6 months.", + "The transfusions did not yield the expected results.", + "The transfusions indirectly confirmed a chronic loss via the duodenal collaterals.", + "Another computed tomography of the abdomen confirmed the previous findings.", + "The patient was referred to a surgical clinic for a consultation.", + "An elective surgery was scheduled for the following month.", + "The patient was treated with repeated intravenous iron supplementation.", + "Hemostasis parameters were corrected.", + "The patient was slightly pale upon admission to the surgical ward.", + "A physical examination produced no remarkable findings.", + "The patient underwent surgery under general anaesthesia.", + "Mobilisation of the malrotated bowel was performed.", + "An anastomosis was created between the large collateral arising from the distal section of the SMV and the anterior inferior pancreaticoduodenal vein.", + "The anastomosis was created without any prosthetic material.", + "Intravenous heparin (100 units per kg) was administered.", + "Some dilated veins on the duodenal surface were ligated.", + "The ligation aimed to interrupt the blood flow in the duodenal varices.", + "The postoperative period was unremarkable.", + "The patient was discharged to outpatient care.", + "Anticoagulant treatment with low molecular weight heparins was started.", + "Five months after the surgical intervention, a CT of the abdomen was performed.", + "The CT confirmed the patency of the venous anastomosis.", + "The CT showed diminution of duodenal varices.", + "A slightly stenotic passage through the anastomosis was observed.", + "A regression of the duodenal varices draining into the SMV was observed.", + "Two months later, the patient underwent an upper gastrointestinal endoscopy.", + "The endoscopy was intended to ligate the residual duodenal varices.", + "The patient still has three large duodenal varices.", + "The three large duodenal varices have been left untreated.", + "The patient has no clinical signs of bleeding.", + "The patient has no anaemia or iron deficiency." + ], + "summary": "We present the case of a 22-year-old patient who had been diagnosed with iron deficiency anaemia at the age of two months. As a result of the absence of the proximal section of the superior mesenteric vein, the patient has always needed iron supplements and an occasional erythrocyte transfusion. This has resulted from the formation of collaterals throughout the small bowel, causing chronic blood loss with its clinical manifestation. Although, there are some congenital abnormalities of the superior mesenteric vein, the absence of the superior mesenteric vein is rare, and in this case the clinical course was quite severe. Therefore, we planned bypass surgery for this patient to reduce the duodenal collaterals and resolve the persistent anaemia caused by chronic blood loss from the duodenum. We successfully performed the surgery consisting of the formation of anastomosis between the large collateral vein from the distal end of the superior mesenteric vein and the anterior inferior pancreaticoduodenal vein.", + "summary_subclaims": [ + "The patient is a 22-year-old.", + "The patient had been diagnosed with iron deficiency anaemia at the age of two months.", + "The patient has always needed iron supplements.", + "The patient has needed an occasional erythrocyte transfusion.", + "The patient has chronic blood loss with its clinical manifestation.", + "The patient has congenital abnormalities of the superior mesenteric vein.", + "The absence of the proximal section of the superior mesenteric vein is rare.", + "The clinical course was quite severe.", + "We planned bypass surgery for this patient.", + "The surgery consisted of the formation of anastomosis between the large collateral vein from the distal end of the superior mesenteric vein and the anterior inferior pancreaticoduodenal vein." + ] + }, + { + "id": "multiclinsum_test_3233_en.txt", + "fulltext": "Female patient, 13 years old, from Cajamarca (Peru's highlands) and from Lima, with no relevant pathological or surgical history.\n\nShe consulted in the emergency department due to diffuse and intermittent abdominal pain of 1 month evolution, which subsided with oral analgesics, associated with weight loss. One week prior to admission, the patient developed intermittent fever, nausea and vomiting after eating and a progressive increase in the intensity of abdominal pain.\n\nOn admission, the abdominal physical examination did not reveal air-bubble sounds; superficial palpation revealed pain that increased in the left hypochondrium, where the spleen was palpated 3 cm below the left costal margin. Deep palpation revealed pain that increased in the mesogastrium. Laboratory studies reported anemia with a hemoglobin value of 10.1 g/dL (VN: 12-16); neutrophil count of 7.85 x 103/uL (VN: 1.8-8), platelets of 371 x 103/uL (VN: 150-350), lactate dehydrogenase (LDH) of 4,242 U/L (VN: 240-435) and a sedimentation rate of 35 mm/h (VN: 0-20). Serology for hepatitis B and C, HIV, syphilis and Koch bacillus (BK) in sputum and faeces was negative.\n\nIn the presence of suspected surgical acute abdomen, an abdominal tomography was performed, which showed two areas with intussusception, one at the ileo-ileal level and another at the mesenterio-ileal level, and a spleen of normal size for the age, but with the presence of a solid mass of 34 x 41 x 43 mm in size, with soft parts density, in addition to a hypodens mass of 30 x 42 x 77 mm in size, with probable ganglion conglomerate at the level of the splenic hilum.\n\nFollowing the CT scan, laboratory tests were expanded and a B2 microglobulin value of 2.79 mg/L (normal range: 0.8-2.2) and a positive viral load for EBV of 227 copies/ml were observed. Tumour markers such as carcinoembryonic antigen and alpha-fetoprotein, as well as TORCH IgM serology (Toxoplasma, Rubella, Cytomegalovirus, Herpes) were negative; immunoglobulins remained within the appropriate ranges.\n\nA percutaneous ultrasound-guided biopsy of the splenic mass was performed. The histopathological analysis revealed a lymphoid proliferation of medium-sized, monotonous cells with round nuclei, clumped chromatin, interspersed with histiocytes and staining bodies (so-called \"starry sky\" appearance). Immunohistochemical markers (BCL6+, CD10+, BCL2-, TdT-, CD30-, LMP1 (EBV)-, CD21-, Ki close to 100%, cMYC+, MUM1-, CD5-, CD3-) were analyzed and were consistent with the final diagnosis of Burkitt's lymphoma.\n\nFollow-up tests: bone marrow biopsy and flow cytometry of cerebrospinal fluid (CSF) were negative for marrow and central nervous system (CNS) infiltration. However, cytospin analysis of CSF was positive for the presence of lymphoid neoplasm, which was classified as clinical stage IV by Murphy.\n\nBefore the beginning of systemic therapy, the patient presented a negative evolution related to the intussusception, for which an exploratory laparotomy was performed. During the procedure, an ileo-ileal intussusception was found 70 cm from the Treitz angle, with an invaginated area of 20 cm, in addition to multiple areas of thickening of the wall of thin loops, which in the context of the patient were attributed to infiltration by the lymphoma diagnosed by the biopsy of the tumor in the spleen. The intussusception was disinvaginated. In the postoperative period, total parenteral nutrition support was used and the antibiotic coverage was expanded to meropenem, vancomycin and caspofungin, due to persistence of fever and elevation of inflammatory parameters.\n\nWith clinical improvement, the patient initiated chemotherapy according to institutional protocol based on the BFM-NHL95 scheme for risk group R4 for detection of malignant neoplasia by cytomorphology of the cerebrospinal fluid. Ultrasound checks were performed to rule out the appearance of new foci of intussusception. After completing the first cycle of chemotherapy, no new foci of intussusception were detected by ultrasound; consequently, the patient tolerated oral diet, so total parenteral nutrition was suspended. Studies were performed to rule out CNS infections due to the appearance of post chemotherapy headaches, with negative viral loads. In addition, flow cytometry was repeated and was negative; while cytospin showed a positive result for lymphoid neoplasia.\n\nA positron emission tomography-computed tomography (PET-CT) was performed after her first cycle of treatment, which showed the disappearance of intussusception foci and the absence of hypermetabolic foci in intestinal walls, in the splenic lesion and at the CNS level. After 2 years of follow-up, the patient is asymptomatic, with a PET-CT negative for lymphoproliferative disease.\n", + "fulltext_subclaims": [ + "The patient is a 13-year-old female.", + "The patient is from Cajamarca and Lima.", + "The patient has no relevant pathological or surgical history.", + "She consulted in the emergency department due to diffuse and intermittent abdominal pain of 1 month evolution.", + "The abdominal pain subsided with oral analgesics.", + "The patient had associated weight loss.", + "One week prior to admission, the patient developed intermittent fever.", + "One week prior to admission, the patient developed nausea and vomiting after eating.", + "One week prior to admission, the patient had a progressive increase in the intensity of abdominal pain.", + "On admission, the abdominal physical examination did not reveal air-bubble sounds.", + "Superficial palpation revealed pain that increased in the left hypochondrium.", + "The spleen was palpated 3 cm below the left costal margin.", + "Deep palpation revealed pain that increased in the mesogastrium.", + "Laboratory studies reported anemia with a hemoglobin value of 10.1 g/dL.", + "The neutrophil count was 7.85 x 103/uL.", + "The platelet count was 371 x 103/uL.", + "The lactate dehydrogenase (LDH) was 4,242 U/L.", + "The sedimentation rate was 35 mm/h.", + "Serology for hepatitis B and C, HIV, syphilis and Koch bacillus (BK) in sputum and faeces was negative.", + "An abdominal tomography showed two areas with intussusception, one at the ileo-ileal level and another at the mesenterio-ileal level.", + "The spleen was of normal size for the age.", + "There was a solid mass of 34 x 41 x 43 mm in size with soft parts density.", + "There was a hypodens mass of 30 x 42 x 77 mm in size with probable ganglion conglomerate at the level of the splenic hilum.", + "A B2 microglobulin value of 2.79 mg/L was observed.", + "A positive viral load for EBV of 227 copies/ml was observed.", + "Tumour markers such as carcinoembryonic antigen and alpha-fetoprotein were negative.", + "TORCH IgM serology (Toxoplasma, Rubella, Cytomegalovirus, Herpes) was negative.", + "Immunoglobulins remained within the appropriate ranges.", + "A percutaneous ultrasound-guided biopsy of the splenic mass was performed.", + "The histopathological analysis revealed a lymphoid proliferation of medium-sized, monotonous cells with round nuclei.", + "The histopathological analysis showed clumped chromatin.", + "The histopathological analysis showed interspersed histiocytes and staining bodies.", + "The histopathological analysis showed a 'starry sky' appearance.", + "Immunohistochemical markers BCL6+ were analyzed.", + "Immunohistochemical markers CD10+ were analyzed.", + "Immunohistochemical markers BCL2- were analyzed.", + "Immunohistochemical markers TdT- were analyzed.", + "Immunohistochemical markers CD30- were analyzed.", + "Immunohistochemical markers LMP1 (EBV)- were analyzed.", + "Immunohistochemical markers CD21- were analyzed.", + "Immunohistochemical markers Ki close to 100% were analyzed.", + "Immunohistochemical markers cMYC+ were analyzed.", + "Immunohistochemical markers MUM1- were analyzed.", + "Immunohistochemical markers CD5- were analyzed.", + "Immunohistochemical markers CD3- were analyzed.", + "The final diagnosis was Burkitt's lymphoma.", + "A bone marrow biopsy was negative.", + "Flow cytometry of cerebrospinal fluid (CSF) was negative for marrow and central nervous system (CNS) infiltration.", + "Cytospin analysis of CSF was positive for the presence of lymphoid neoplasm.", + "The patient was classified as clinical stage IV by Murphy.", + "An exploratory laparotomy was performed.", + "An ileo-ileal intussusception was found 70 cm from the Treitz angle.", + "The invaginated area was 20 cm.", + "Multiple areas of thickening of the wall of thin loops were found.", + "The thickening of the wall of thin loops was attributed to infiltration by the lymphoma.", + "The intussusception was disinvaginated.", + "Total parenteral nutrition support was used in the postoperative period.", + "Antibiotic coverage was expanded to meropenem, vancomycin and caspofungin.", + "The patient initiated chemotherapy according to institutional protocol based on the BFM-NHL95 scheme.", + "The patient was in risk group R4 for detection of malignant neoplasia by cytomorphology of the cerebrospinal fluid.", + "Ultrasound checks were performed to rule out the appearance of new foci of intussusception.", + "After completing the first cycle of chemotherapy, no new foci of intussusception were detected by ultrasound.", + "The patient tolerated oral diet after completing the first cycle of chemotherapy.", + "Total parenteral nutrition was suspended.", + "Studies were performed to rule out CNS infections due to the appearance of post chemotherapy headaches.", + "Viral loads were negative.", + "Flow cytometry was repeated and was negative.", + "Cytospin showed a positive result for lymphoid neoplasia.", + "A PET-CT was performed after her first cycle of treatment.", + "The PET-CT showed the disappearance of intussusception foci.", + "The PET-CT showed the absence of hypermetabolic foci in intestinal walls.", + "The PET-CT showed the absence of hypermetabolic foci in the splenic lesion.", + "The PET-CT showed the absence of hypermetabolic foci at the CNS level.", + "After 2 years of follow-up, the patient is asymptomatic.", + "A PET-CT after 2 years of follow-up was negative for lymphoproliferative disease." + ], + "summary": "13-year-old female patient with abdominal pain, progressive weight loss and fever. Imaging studies showed a splenic mass, intestinal thickening and ileal intussusception. A biopsy of the spleen was performed and histopathological analysis revealed a Burkitt's lymphoma. The patient's abdominal symptoms resolved, no other signs of intussusception were observed and a marked reduction in the splenic mass was evident after the first cycle of chemotherapy based on the institutional protocol (BFM95-NHL).\n", + "summary_subclaims": [ + "The patient is a 13-year-old female.", + "The patient had abdominal pain.", + "The patient had progressive weight loss.", + "The patient had fever.", + "Imaging studies showed a splenic mass.", + "Imaging studies showed intestinal thickening.", + "Imaging studies showed ileal intussusception.", + "A biopsy of the spleen was performed.", + "Histopathological analysis revealed a Burkitt's lymphoma.", + "The patient's abdominal symptoms resolved.", + "No other signs of intussusception were observed.", + "A marked reduction in the splenic mass was evident after the first cycle of chemotherapy.", + "The chemotherapy was based on the institutional protocol (BFM95-NHL)." + ] + }, + { + "id": "multiclinsum_test_539_en.txt", + "fulltext": "An eight-year-old boy referred to our clinic manifested with pain along with swelling in mandibular incisors for the past one month, especially the past week. No relevant medical, family or psychosocial history was reported. There was no abnormality on extraoral examination. An abnormal coronal anatomy of the bilateral mandibular central incisors was found on intraoral examination. The conical crown had a deep depression with a talon cusp on the conical crown, and caries or restorations were not found in the teeth. There was a giant abscess on the labial gingiva of the left mandibular central incisor, which exhibited pain on vertical percussion and degree II tooth mobility. Concurrently, there was a fistula on the distal and lingual gum of the right mandibular central incisor, which exhibited slightly pain on vertical percussion and degree-I tooth mobility .\nRadiographic examination showed periapical radiolucency exhibiting a scantly defined border, as well as an invagination which had a central invaginated canal extending from the pulp chamber throughout the apical foramen in the mandibular central incisors . This type of anatomy was consistent with a DI Odhlers type IIIb. Although there was no response on the electric pulp vitality test, there were doubts about the dependability of this result due to immature development of the root with an open apex. We performed a CBCT (cone‑beam computed tomography) scan as a complementary examination to acquire more comprehensive anatomic information and an accurate diagnosis. The CBCT images exhibited an invagination of the bilateral mandibular central incisors extending from the crown throughout to the root canal apex; however there was no communication with the main root canal. The apical foramen was incomplete and had a large area of periapical radiolucency of approximately 5.2 × 7.8 mm in the left mandibular central incisor and approximately 4.1 × 6.4 mm in the right mandibular central incisor .\nWe diagnosed the case as DI with chronic apical periodontitis. Extraction and orthodontic intervention are important because of the complex root involvement and the uncertain prognosis of conservative therapy. Nevertheless, the patient’s parents hoped to retain the natural teeth. Endodontic therapy was selected as the preferred treatment plan.\nAccording to the radiographic examination, we found that there was no communication between the invagination and the main root canal. It was postulated that the pain and infection were caused by infection in the invagination, while the main root canal pulp remained vital. Under rubber dam isolation and a dental surgical microscope (Leica M330; Leica microsystems, Wetzlar, Germany), conservative endodontic access into the invagination was made using a small round bur, while the main root canal pulp was not exposed. The orifice of the invagination was confirmed with an endodontic explorer and 15# K-file. No penetration was observed between the invaginated canal and the main root canal. At the same time, the periapical tissues discharged a bloody and purulent exudate. Stainless-steel hand K-files along with nickel-titanium rotary instruments were employed to instrument the invaginated canal; however, with caution not to surpass the length of the canal. In the process, the invagination was irrigated thoroughly with 1.5% sodium hypochlorite solution (NaOCl) and 0.9% saline solution. Moreover, a sonic-activated device was employed to attain a more effective debridement. It was necessary to irrigate the invagination thoroughly due to the complex canal structure. Paper points were employed to dry the invaginated canal, followed by application of paste of calcium hydroxide, and then temporary filling material (Caviton; GC Co., Tokyo, Japan) was employed to seal the access cavity.\nDuring the second appointment after 2 weeks, the patient felt well, and the fistula on the distal and lingual gum of the right mandibular central incisor had disappeared. The giant abscess on the labial gingiva of the left mandibular central incisor was relieved but not healed. Abundant irrigation using 17% ethylenediaminetetraacetic acid (EDTA) solution was employed to remove the intracanal dressing of the invagination along with the smear layer. Subsequently, copious 1.5% NaOCl and saline with the sonic-activated device were applied. After that, paper points were employed to dry the invaginated canal, which was then obturated with the Vitapex (Neo dental co., Tokyo, Japan). Then we took the radiographic imaging of the teeth to confirm the position of the Vitapex , and GIC (glass ionomer cement) (GlasIonomer FX-II; Shofu Inc, Kyoto, Japan) was used to seal the access cavity.\nAt the third appointment after 1 month, the patient felt well, and the right mandibular central incisor had no clinical signs or symptoms. There was still an abscess on the labial gingiva of the left mandibular central incisor, although it was smaller. For the right mandibular central incisor, Vitapex was obturated in the invagination canal to induce root development, and then used GIC and composite resin (Z350; 3M ESPE, St Paul, MN, USA) to seal the access cavity. For the left mandibular central incisor, it was identified that main root canal pulp was infected, and treatment was required. Under local anesthesia utilizing articaine with 1:10,000 epinephrine, small round bur was employed to prepare an endodontic access to the main root canal, and the pulp was found to be necrotic. A stainless-steel hand K-files was employed to simply instrument the main root canal and was irrigated abundantly with 1.5% NaOCl and 0.9% saline solution with a sonic-activated device to obtain more effective chemical debridement. Paper points were used to dry the main root canal, followed by application of calcium hydroxide paste via syringe, and the access cavity was sealed with GIC. At the same time, we replaced the dressing in the invagination with Vitapex .\nAt the fourth appointment after three weeks, there were no clinical signs or symptoms of the left mandibular central incisor. 2% mepivacaine hydrochloride (no epinephrine) was used to perform local anesthesia, followed by reaccession of the main root canal. Next, 0.9% saline along with a sonic-activated device were utilized to remove the calcium hydroxide paste. Gentle irrigation of the canal with 17% EDTA solution (20 mL) was performed and followed by drying using paper points. The canal was over-instrumented with a precurved K-file extending 2 mm past the apical foramen, to induce bleeding. The instrument was extended 3–4 mm below the CEJ (cementoenamel junction) to allow formation of a bold clot. We placed an iRoot BP Plus (Innovative BioCeramix, Vancouver, BC, Canada) on top of the blood clot. At the same time, iRoot SP (Innovative BioCeramix) and warm gutta-percha obturation replaced the Vitapex in the invaginated root canal. Then, the tooth was sealed with GIC and was restored using a composite resin. A radiographic image verified the position of the iRoot BP Plus .\nEighteen months later, there were no clinical signs or symptoms of the mandibular central incisors. According to the radiographic image, the open apex was closed, and the root continued to develop. Therefore, iRoot SP and warm gutta-percha obturation replaced the Vitapex in the invaginated root canal of the right mandibular central incisor, and then the tooth was finally restored with composite resin .", + "fulltext_subclaims": [ + "An eight-year-old boy had pain and swelling in mandibular incisors for the past one month.", + "The pain and swelling had worsened in the past week.", + "There was no relevant medical, family, or psychosocial history.", + "Extraoral examination showed no abnormality.", + "Intraoral examination found an abnormal coronal anatomy of the bilateral mandibular central incisors.", + "The conical crown had a deep depression with a talon cusp.", + "Caries or restorations were not found in the teeth.", + "A giant abscess was on the labial gingiva of the left mandibular central incisor.", + "The left mandibular central incisor exhibited pain on vertical percussion.", + "The left mandibular central incisor had degree II tooth mobility.", + "A fistula was on the distal and lingual gum of the right mandibular central incisor.", + "The right mandibular central incisor exhibited slightly pain on vertical percussion.", + "The right mandibular central incisor had degree-I tooth mobility.", + "Radiographic examination showed periapical radiolucency with a scantly defined border.", + "Radiographic examination showed an invagination with a central invaginated canal extending from the pulp chamber throughout the apical foramen.", + "The anatomy was consistent with DI Odhlers type IIIb.", + "There was no response on the electric pulp vitality test.", + "Doubts were raised about the dependability of the electric pulp vitality test due to immature root development with an open apex.", + "A CBCT scan was performed as a complementary examination.", + "CBCT images showed invagination of the bilateral mandibular central incisors extending from the crown throughout to the root canal apex.", + "There was no communication between the invagination and the main root canal.", + "The apical foramen was incomplete.", + "The left mandibular central incisor had a periapical radiolucency of approximately 5.2 × 7.8 mm.", + "The right mandibular central incisor had a periapical radiolucency of approximately 4.1 × 6.4 mm.", + "The diagnosis was DI with chronic apical periodontitis.", + "Extraction and orthodontic intervention were considered important due to complex root involvement and uncertain prognosis of conservative therapy.", + "The patient’s parents hoped to retain the natural teeth.", + "Endodontic therapy was selected as the preferred treatment plan.", + "There was no communication between the invagination and the main root canal.", + "It was postulated that the pain and infection were caused by infection in the invagination.", + "The main root canal pulp was postulated to remain vital.", + "Conservative endodontic access into the invagination was made using a small round bur.", + "The main root canal pulp was not exposed.", + "The orifice of the invagination was confirmed with an endodontic explorer and 15# K-file.", + "No penetration was observed between the invaginated canal and the main root canal.", + "The periapical tissues discharged a bloody and purulent exudate.", + "Stainless-steel hand K-files and nickel-titanium rotary instruments were used to instrument the invaginated canal.", + "The invaginated canal was irrigated with 1.5% sodium hypochlorite solution and 0.9% saline solution.", + "A sonic-activated device was used to attain more effective debridement.", + "Paper points were used to dry the invaginated canal.", + "Calcium hydroxide paste was applied to the invaginated canal.", + "Temporary filling material (Caviton) was used to seal the access cavity.", + "During the second appointment after 2 weeks, the fistula on the distal and lingual gum of the right mandibular central incisor had disappeared.", + "The giant abscess on the labial gingiva of the left mandibular central incisor was relieved but not healed.", + "17% EDTA solution was used to remove the intracanal dressing and smear layer.", + "1.5% NaOCl and saline with a sonic-activated device were applied.", + "Vitapex was used to obturate the invaginated canal.", + "Radiographic imaging confirmed the position of the Vitapex.", + "GIC was used to seal the access cavity.", + "At the third appointment after 1 month, the right mandibular central incisor had no clinical signs or symptoms.", + "There was still an abscess on the labial gingiva of the left mandibular central incisor.", + "For the right mandibular central incisor, Vitapex was obturated in the invagination canal.", + "GIC and composite resin were used to seal the access cavity of the right mandibular central incisor.", + "For the left mandibular central incisor, the main root canal pulp was identified as infected.", + "Local anesthesia with articaine and 1:10,000 epinephrine was used.", + "A small round bur was used to prepare an endodontic access to the main root canal.", + "The pulp was found to be necrotic.", + "Stainless-steel hand K-files were used to instrument the main root canal.", + "The main root canal was irrigated with 1.5% NaOCl and 0.9% saline solution.", + "A sonic-activated device was used for chemical debridement.", + "Calcium hydroxide paste was applied to the main root canal.", + "The access cavity was sealed with GIC.", + "The dressing in the invagination was replaced with Vitapex.", + "At the fourth appointment after three weeks, there were no clinical signs or symptoms of the left mandibular central incisor.", + "2% mepivacaine hydrochloride was used for local anesthesia.", + "The main root canal was reaccessed.", + "0.9% saline with a sonic-activated device was used to remove the calcium hydroxide paste.", + "17% EDTA solution was used for irrigation.", + "The canal was over-instrumented with a precurved K-file extending 2 mm past the apical foramen.", + "The instrument was extended 3–4 mm below the CEJ.", + "iRoot BP Plus was placed on top of the blood clot.", + "iRoot SP and warm gutta-percha obturation replaced the Vitapex in the invaginated root canal.", + "The tooth was sealed with GIC and restored with composite resin.", + "A radiographic image verified the position of the iRoot BP Plus.", + "Eighteen months later, there were no clinical signs or symptoms of the mandibular central incisors.", + "The radiographic image showed the open apex was closed.", + "The root continued to develop.", + "iRoot SP and warm gutta-percha obturation replaced the Vitapex in the invaginated root canal of the right mandibular central incisor.", + "The tooth was finally restored with composite resin." + ], + "summary": "An eight-year-old boy referred to our clinic manifesting with pain along with swelling in the mandibular incisors for the past one month. Radiographic examination showed periapical radiolucency exhibiting a scantly defined border, as well as an invagination which had a central invaginated canal extending from the pulp chamber throughout the apical foramen in both mandibular central incisors. We performed two different treatment procedures on the basis of the condition of the main pulp of the mandibular central incisors. in which only the invagination root canal was treated in the right mandibular central incisor, while the invagination and main root canals were treated in the left mandibular central incisor. During the 18-month follow-up period, the teeth were clinically asymptomatic. Imaging examinations indicated complete healing of the periapical lesion and revealed that the wall of the root canal was thickened and the open apex was closed.", + "summary_subclaims": [ + "An eight-year-old boy referred to our clinic manifesting with pain along with swelling in the mandibular incisors for the past one month.", + "Radiographic examination showed periapical radiolucency exhibiting a scantly defined border.", + "Radiographic examination showed an invagination which had a central invaginated canal extending from the pulp chamber throughout the apical foramen in both mandibular central incisors.", + "We performed two different treatment procedures on the basis of the condition of the main pulp of the mandibular central incisors.", + "Only the invagination root canal was treated in the right mandibular central incisor.", + "The invagination and main root canals were treated in the left mandibular central incisor.", + "During the 18-month follow-up period, the teeth were clinically asymptomatic.", + "Imaging examinations indicated complete healing of the periapical lesion.", + "Imaging examinations revealed that the wall of the root canal was thickened.", + "Imaging examinations revealed that the open apex was closed." + ] + }, + { + "id": "multiclinsum_test_2703_en.txt", + "fulltext": "A 7-month-old girl was referred to the pediatric clinic with developmental delay and failure to thrive. Her family history and antenatal course were unremarkable. At presentation, she was noted to have central hypotonia, hyporeflexia, and dysmorphic features including high arched palate, narrow palpebral fissures and inverted nips. There were prominent fat pads on her supragluteal regions and global developmental delay. At admission, her respiratory and myocardial functions were deteriorated and there was an escalating pericardial effusion and we had to perform pericardiocentesis for two times and as it did not resolve, a pericardial window had to be opened in order to drain the effusion and a pericardial biopsy was also performed.\nThe pericardial effusion was sero-sanguinolent and the biopsy revealed mild inflammation and fibrous thickening of peritoneum. Investigations for a metabolic etiology at this time confirmed normal levels of urine amino acids and organic acids. Blood measurements including levels of plasma amino acids, biotinidase, ammonia, vitamin B12 and lactate were all normal. There was no documented episode of hypoglycemia, presence of urinary ketones and/or metabolic acidosis. TORCH panel involving testing for antibodies to Toxoplasma gondii, rubella, cytomegalovirus and herpes simplex virus was negative. Abdominal ultrasound revealed hyperechogenicity of the renal parenchyma. Magnetic resonance imaging of brain revealed a cerebellar vermis hypoplasia and a generalized reduction in myelination . The child was felt to have a phenotype classic of the CDG-Ia. Isoelectric focusing of transferrin showed a pattern consistent with CDG-Ia. Genetic analysis revealed that she was homozygote c.[385G>A]+[385G>A] for pathogenic mutation in phosphomannomutase 2 (PMM2) gene, consistent with a diagnosis of CDG-Ia. In 14th month of follow-up, the pericardial effusion did not recur; the general condition is good with normal heart functions.", + "fulltext_subclaims": [ + "The patient is a 7-month-old girl.", + "She was referred to the pediatric clinic with developmental delay and failure to thrive.", + "Her family history and antenatal course were unremarkable.", + "At presentation, she had central hypotonia.", + "At presentation, she had hyporeflexia.", + "At presentation, she had dysmorphic features including high arched palate.", + "At presentation, she had dysmorphic features including narrow palpebral fissures.", + "At presentation, she had dysmorphic features including inverted nips.", + "There were prominent fat pads on her supragluteal regions.", + "She had global developmental delay.", + "At admission, her respiratory and myocardial functions were deteriorated.", + "There was an escalating pericardial effusion.", + "Pericardiocentesis was performed for two times.", + "A pericardial window had to be opened in order to drain the effusion.", + "A pericardial biopsy was performed.", + "The pericardial effusion was sero-sanguinolent.", + "The pericardial biopsy revealed mild inflammation.", + "The pericardial biopsy revealed fibrous thickening of peritoneum.", + "Investigations for a metabolic etiology at this time confirmed normal levels of urine amino acids.", + "Investigations for a metabolic etiology at this time confirmed normal levels of organic acids.", + "Blood measurements including levels of plasma amino acids were normal.", + "Blood measurements including levels of biotinidase were normal.", + "Blood measurements including levels of ammonia were normal.", + "Blood measurements including levels of vitamin B12 were normal.", + "Blood measurements including levels of lactate were normal.", + "There was no documented episode of hypoglycemia.", + "There was no documented presence of urinary ketones.", + "There was no documented presence of metabolic acidosis.", + "The TORCH panel was negative.", + "Abdominal ultrasound revealed hyperechogenicity of the renal parenchyma.", + "Magnetic resonance imaging of the brain revealed cerebellar vermis hypoplasia.", + "Magnetic resonance imaging of the brain revealed generalized reduction in myelination.", + "The child was felt to have a phenotype classic of CDG-Ia.", + "Isoelectric focusing of transferrin showed a pattern consistent with CDG-Ia.", + "Genetic analysis revealed she was homozygote c.[385G>A]+[385G>A] for pathogenic mutation in phosphomannomutase 2 (PMM2) gene.", + "The diagnosis was consistent with CDG-Ia.", + "In the 14th month of follow-up, the pericardial effusion did not recur.", + "In the 14th month of follow-up, the general condition is good.", + "In the 14th month of follow-up, heart functions are normal." + ], + "summary": "Herein, we describe a case of congenital disorder of glycosylation Ia, presented with recurrent pericardial effusion and unusual findings of inverted nipples, fat pads, reduced deep-tendon reflexes and multisystem involvement.", + "summary_subclaims": [ + "The case described is of congenital disorder of glycosylation Ia.", + "The patient presented with recurrent pericardial effusion.", + "The patient had unusual findings of inverted nipples.", + "The patient had fat pads.", + "The patient had reduced deep-tendon reflexes.", + "The patient had multisystem involvement." + ] + }, + { + "id": "multiclinsum_test_1932_en.txt", + "fulltext": "A 76-year-old female presented with MDD with inadequate response to antidepressants, post-traumatic stress disorder, obsessive compulsive disorder, generalized anxiety disorder, pseudobulbar affect, insomnia, restless leg syndrome, constipation, back pain, gastroesophageal reflux disease, hyperlipidemia, and glaucoma. Smoking status was not disclosed. Hepatic, kidney, and thyroid function laboratory values were all within normal limits (e.g., albumin, AST, ALT, creatinine, BUN, total protein, globulin, alkaline phosphatase, and bilirubin total, thyroid-stimulating hormone). The medications prescribed by the primary care provider (PCP) to manage her various medical conditions are listed in Table .\nThe patient’s chief complaint was uncontrolled depression despite multiple attempts with various antidepressants. These medications include bupropion, escitalopram, and venlafaxine which all resulted in the patient experiencing ADEs and/or inadequate depression control. In brief and based on medical history, the patient was initially started on bupropion which was discontinued as she experienced uncontrolled shaking. Escitalopram was then used for 2 months and was discontinued due to an unknown reaction. Subsequently, venlafaxine was used for 3 months without favorable outcomes. This led to the introduction of other medications, such as: sertraline, risperidone and duloxetine. Additionally, this patient was also treated with quetiapine, although initiation date of treatment was unknown. The timeline for her antidepressant trials and other concomitant medications, including prescription and over the counter, is depicted in Table .\nThis participant had recently enrolled in the Program of All-inclusive Care for the Elderly (PACE). Within the PACE model, pharmacists and other healthcare practitioners collaborate to identify and mitigate medication-related problems . PGx testing is one of the initiatives utilized to further improve the care of PACE participants. Being newly introduced to the management of this patient, a clinical pharmacist recommended a PGx test to optimize MDD management; this recommendation was accepted by the PCP. A DNA sample was collected via buccal swab and analyzed by a genetic laboratory (CQuentia, Memphis, TN; Genetic Response Report) and the clinical pharmacist was consulted to interpret relevant pharmacogenomic results. The patient was identified as a CYP2C19 IM, with a CYP2C19*2|*17 genotype, and as a CYP2D6 IM, with a CYP2D6*1|*4 genotype.\nAlthough the clinical pharmacist assessed the complete drug regimen, only recommendations relevant to antidepressant and antipsychotic therapies will be discussed in this case report. It is also worth acknowledging that although the patient’s chief complaint was uncontrolled depression and focus was on the MDD diagnosis, there are common symptoms with regards to her present psychiatric comorbidities. DGIs were considered relevant for the metabolism of duloxetine and risperidone (CYP2D6), and for the disposition of sertraline (CYP2C19). The CYP2D6 IM phenotype is associated with reduced enzyme activity and decreased clearance of CYP2D6 substrates. Hence, the risk of toxicity is increased for risperidone and to a lesser extent for duloxetine; it should be noted that the major metabolic pathway for duloxetine is through CYP1A2 (70%), while the contribution of 2D6 is limited to 30%. Similarly, a CYP2C19 IM has reduced enzyme activity, which results in decreased sertraline clearance and increased risk of toxicity.\nThe clinical pharmacist also identified three clinically significant DDIs . Quinidine, a potent CYP2D6 inhibitor, is expected to inhibit the metabolism of risperidone and duloxetine. Such inhibition occurs regardless of the time of administration of the drugs as this interaction is mechanistically a non-competitive inhibition. The CDSS, which is based on algorithms and several pharmacological factors, was used to determine the presence of drug-induced phenoconversion (patent: WO 2019/089725). Quinidine inhibition of CYP2D6 resulted in phenoconversion whereby this patient’s phenotype is converted from a CYP2D6 IM to a PM phenotype. When this interaction occurs, the plasma concentrations of risperidone and duloxetine are likely to be higher than predicted from the genotypic results alone. Lastly, DDIs were also identified by the CDSS on the CYP3A4 metabolic pathway; risperidone and quinidine are drugs with stronger affinity for the CYP3A4 enzyme than quetiapine. Consequently, these drugs are expected to competitively inhibit the metabolism of quetiapine when co-administered. When this interaction occurs, the plasma concentrations of quetiapine are likely to be significantly higher than predicted (CYP3A4 contributes to 75% of the total clearance of quetiapine), increasing the risk for toxicity. A similar mechanism of DDI occurs between sertraline —a CYP3A4 substrate with low affinity— risperidone, and quetiapine. CYP3A4 is responsible of 25% of the total clearance of sertraline, leading to moderately clinically significant changes in plasma concentrations of sertraline (if only this route of elimination is affected).\nWhen performing the assessment and making recommendations, the clinical pharmacist considered several factors including previous unsuccessful medication trials, PGx test results and concomitant medications. Quetiapine has a low affinity for the dopamine 2 receptor, which is required for antipsychotic efficacy, therefore higher doses may be required for clinical effects for mood disorders and agitation. Additionally, quetiapine has mixed results for the treatment of dementia psychosis and agitation . Given this information and the DDI impacting the metabolism of quetiapine at CYP3A4, it was recommended that the PCP taper off the quetiapine while simultaneously optimizing the risperidone dose and frequency (targeting the lowest effective dose). Continued monitoring (e.g., EKG, palpitations) for risperidone was also suggested due to an increased risk of QTc prolongation caused by the presence of a DGI and a DDI at CYP2D6, and by the combination of quinidine , risperidone , rosuvastatin , quetiapine , and pantoprazole , which have all been associated with drug-induced QTc prolongation. Furthermore, it was recommended to optimize antidepressant therapy dosing based on clinical response and presence of ADEs.\nOver the next 8 weeks the aforementioned recommendations were accepted by the PCP, who before implementing had a thorough discussion with the patient’s psychiatrist to account for other non-PGx factors. Tapering of the quetiapine dose was attempted and risperidone did not require a further increase in dose. Antidepressant therapy was optimized by increasing the duloxetine dose from 30 mg to 60 mg daily, the patient was monitored closely during dose escalation. It was determined that the dose of sertraline would be re-assessed based upon therapeutic response to these changes. The PCP reported that the patient was experiencing less anxiety and better control of depression as frequent monitoring was continued.", + "fulltext_subclaims": [ + "The patient is a 76-year-old female.", + "The patient had post-traumatic stress disorder.", + "The patient had generalized anxiety disorder.", + "The patient had pseudobulbar affect.", + "The patient had insomnia.", + "The patient had restless leg syndrome.", + "The patient had constipation.", + "The patient had back pain.", + "The patient had gastroesophageal reflux disease.", + "The patient had hyperlipidemia.", + "The patient had glaucoma.", + "Hepatic, kidney, and thyroid function laboratory values were all within normal limits.", + "The patient had a history of uncontrolled depression despite multiple attempts with various antidepressants.", + "The patient was initially started on bupropion.", + "Bupropion was discontinued as she experienced uncontrolled shaking.", + "Escitalopram was then used for 2 months.", + "Escitalopram was discontinued due to an unknown reaction.", + "Venlafaxine was used for 3 months without favorable outcomes.", + "The patient was treated with sertraline.", + "The patient was treated with risperidone.", + "The patient was treated with duloxetine.", + "The patient was also treated with quetiapine.", + "The initiation date of quetiapine treatment was unknown.", + "The patient had recently enrolled in the Program of All-inclusive Care for the Elderly (PACE).", + "A clinical pharmacist recommended a PGx test to optimize MDD management.", + "The recommendation was accepted by the PCP.", + "A DNA sample was collected via buccal swab.", + "The sample was analyzed by a genetic laboratory (CQuentia, Memphis, TN; Genetic Response Report).", + "The patient was identified as a CYP2C19 intermediate metabolizer.", + "The patient had a CYP2C19*2|*17 genotype.", + "The patient was identified as a CYP2D6 intermediate metabolizer.", + "The patient had a CYP2D6*1|*4 genotype.", + "The CYP2D6 intermediate metabolizer phenotype is associated with reduced enzyme activity.", + "The CYP2D6 intermediate metabolizer phenotype is associated with decreased clearance of CYP2D6 substrates.", + "The risk of toxicity is increased for risperidone in a CYP2D6 intermediate metabolizer.", + "The risk of toxicity is increased for duloxetine in a CYP2D6 intermediate metabolizer.", + "The major metabolic pathway for duloxetine is through CYP1A2.", + "The contribution of CYP2D6 to duloxetine metabolism is limited to 30%.", + "A CYP2C19 intermediate metabolizer has reduced enzyme activity.", + "A CYP2C19 intermediate metabolizer has decreased sertraline clearance.", + "The risk of toxicity is increased for sertraline in a CYP2C19 intermediate metabolizer.", + "Quinidine is a potent CYP2D6 inhibitor.", + "Quinidine is expected to inhibit the metabolism of risperidone.", + "Quinidine is expected to inhibit the metabolism of duloxetine.", + "The inhibition by quinidine occurs regardless of the time of administration.", + "The interaction between quinidine and risperidone is a non-competitive inhibition.", + "The interaction between quinidine and duloxetine is a non-competitive inhibition.", + "The CDSS was used to determine the presence of drug-induced phenoconversion.", + "Quinidine inhibition of CYP2D6 resulted in phenoconversion.", + "The patient’s CYP2D6 phenotype was converted from intermediate metabolizer to poor metabolizer.", + "The plasma concentrations of risperidone are likely to be higher than predicted from genotypic results alone.", + "The plasma concentrations of duloxetine are likely to be higher than predicted from genotypic results alone.", + "Risperidone and quinidine have stronger affinity for the CYP3A4 enzyme than quetiapine.", + "Risperidone and quinidine are expected to competitively inhibit the metabolism of quetiapine.", + "CYP3A4 contributes to 75% of the total clearance of quetiapine.", + "The plasma concentrations of quetiapine are likely to be significantly higher than predicted.", + "The risk for toxicity is increased for quetiapine.", + "A similar mechanism of DDI occurs between sertraline, risperidone, and quetiapine.", + "CYP3A4 is responsible for 25% of the total clearance of sertraline.", + "The plasma concentrations of sertraline are likely to be moderately clinically significant.", + "The clinical pharmacist considered previous unsuccessful medication trials.", + "The clinical pharmacist considered PGx test results.", + "The clinical pharmacist considered concomitant medications.", + "Quetiapine has a low affinity for the dopamine 2 receptor.", + "Higher doses of quetiapine may be required for clinical effects for mood disorders.", + "Quetiapine has mixed results for the treatment of dementia psychosis.", + "It was recommended to taper off quetiapine.", + "It was recommended to optimize the risperidone dose and frequency.", + "It was recommended to target the lowest effective dose of risperidone.", + "It was recommended to monitor for QTc prolongation.", + "The increased risk of QTc prolongation is due to the presence of a DGI and a DDI at CYP2D6.", + "The combination of quinidine, risperidone, rosuvastatin, quetiapine, and pantoprazole is associated with drug-induced QTc prolongation.", + "It was recommended to optimize antidepressant therapy dosing based on clinical response.", + "It was recommended to optimize antidepressant therapy dosing based on the presence of ADEs.", + "The PCP accepted the recommendations.", + "The PCP had a thorough discussion with the patient’s psychiatrist before implementing the recommendations.", + "Tapering of the quetiapine dose was attempted.", + "Risperidone did not require a further increase in dose.", + "The duloxetine dose was increased from 30 mg to 60 mg daily.", + "The patient was monitored closely during dose escalation.", + "The dose of sertraline would be re-assessed based upon therapeutic response.", + "The PCP reported that the patient was experiencing less anxiety.", + "The PCP reported that the patient had better control of depression.", + "Frequent monitoring was continued." + ], + "summary": "A patient with multiple comorbidities, including severe major depressive disorder (MDD), experienced adverse drug events and undesirable response to multiple antidepressant medications (i.e., bupropion, escitalopram, and venlafaxine). A clinical pharmacist assessed significant drug-gene, drug-drug, and drug-drug-gene interactions as well as other clinical factors to provide recommendations for antidepressant therapy optimization.", + "summary_subclaims": [ + "The patient has multiple comorbidities.", + "The patient has severe major depressive disorder.", + "The patient experienced adverse drug events.", + "The patient had an undesirable response to multiple antidepressant medications.", + "The antidepressant medications included bupropion, escitalopram, and venlafaxine.", + "A clinical pharmacist assessed significant drug-gene interactions.", + "A clinical pharmacist assessed significant drug-drug interactions.", + "A clinical pharmacist assessed significant drug-drug-gene interactions.", + "A clinical pharmacist assessed other clinical factors.", + "The clinical pharmacist provided recommendations for antidepressant therapy optimization." + ] + }, + { + "id": "multiclinsum_test_2237_en.txt", + "fulltext": "This case report is a sequel to that by Kabashima et al. An 82-year-old man underwent laparoscopy-assisted partial gastrectomy for gastric tumor at an outside hospital. The gastric tumor was pathologically diagnosed as UPS, which is a rare high-grade sarcoma. The patients’ clinical course after his partial gastrectomy and the case-specific histopathological findings are reported in detail by Kabashima et al. 3 months after the patient’s first surgery, he was referred to our hospital due to new-onset dizziness and headaches. Magnetic resonance imaging (MRI) revealed a large cerebellar tumor with marked peritumoral edema. The tumor had not been present on staging scans (whole-body computed tomography [CT]) conducted immediately after the gastrectomy. On admission, brain CT revealed a 43 mm × 38 mm × 32 mm tumor in the left hemisphere of the cerebellum. MRI revealed that the tumor was iso-to-hyperintense on T1-weighted image (T1WI) and hyperintense on T2WI and demonstrated strong contrast enhancement after gadolinium injection . Fluorodeoxyglucose positron emission-CT (18FDG-PET-CT) revealed FDG uptake of SUV max 7.17. No other region with18FDG uptake was detected.\nThe patient underwent standard suboccipital craniotomy without navigation or monitoring, performed in the prone position, and the cerebellar tumor was completely resected. The consistency of the white–yellow tumor tissue was dense, and the tissue plane between tumor and normal brain was clearly identified and microscopic gross total resection was achieved, and his postoperative course was uneventful. Postoperative MRI (within 24 h) and contrast MRI (within 72 h) revealed complete resection of the tumor . Symptoms improved after surgery, and he had no deficit and was discharged to go home after 20 days from his operation.\nHistopathological analysis showed a proliferation of spindle-to-polygonal-shaped tumor cells with enlarged irregular nuclei and eosinophilic cytoplasm arranged in sheet-like patterns, accompanied by chronic inflammatory infiltration and hemangiopericytomas Staghorn-type branching vessels [ and ]. Employing Ki-67 stains, mitotic figures were frequently observed. Immunohistochemical panel demonstrated that tumor cells were positive for p53 and p16, focally positive for cytokeratin AE1/AE3 CAM5.3, alpha-smooth muscle actin, desmin, and muscle-specific actin (HHF35), but negative for multiple other markers such as cytokeratin CK5/6, CK903, CK14, p40, EMA, GFAP, Oligo-2, IDH-1, ERG, STAT6, and GRIA2. The automated count of MIB-1-labeling index was high and estimated at 37%. We compared brain specimen from the specimen of the stomach after microscopic analysis, and both specimens showed the same histological characteristic. Pathological findings were compatible with that of metastatic tumors from gastric UPS.\nThe patient underwent repeat brain imaging after 1 and ½ months at follow-up, and no apparent brain tumor residual or recurrence was observed. Only 2 weeks after that last visit, the patient started complaining of headache and nausea. A repeat MRI was ordered, which revealed a 4-cm recurrent cerebellar tumor in the same region, indicating that the 4-cm mass must have grown almost entirely within 2 weeks’ window. Since 2 weeks prior, he had undergone a non-contrast CT with 5-mm slice thickness. Systemic restaging was not performed because the pathological diagnosis was not clear. Again, the patient was taken to surgery and the recurrent tumor mass was completely resected. Histopathological findings were indistinguishable from the previous metastatic tumor again with a MIB-1 labeling index of 37%. After the second operation, the patient received focused brain radiation therapy with added local irradiation (40Gy/20Fr) and three dimensional intensity-modulated radiation therapy (30 Gy/3 Fr) to the tumor cavity. However, a second 9-mm metastatic brain tumor appeared in the temporal lobe. In addition, at the time of radiation therapy to the two lesions of the CNS, further metastatic tumors were detected in the patient’s tonsils. Although systemic chemotherapy was initiated adriamycin (30 mg/m2) plus ifosfamide (2 g/m2) (AI) at an age-adjusted dose of 75% and administered together with dexamethasone coverage; the metastatic tonsilar tumor grew rapidly, indicating that chemotherapy was not effective. Further local radiotherapy in this region also had no effect. The patient was thus transferred to a palliative hospital where he expired 10 days later.", + "fulltext_subclaims": [ + "This case report is a sequel to that by Kabashima et al.", + "An 82-year-old man underwent laparoscopy-assisted partial gastrectomy for gastric tumor at an outside hospital.", + "The gastric tumor was pathologically diagnosed as UPS, which is a rare high-grade sarcoma.", + "The patients’ clinical course after his partial gastrectomy and the case-specific histopathological findings are reported in detail by Kabashima et al.", + "3 months after the patient’s first surgery, he was referred to our hospital due to new-onset dizziness and headaches.", + "Magnetic resonance imaging (MRI) revealed a large cerebellar tumor with marked peritumoral edema.", + "The tumor had not been present on staging scans (whole-body computed tomography [CT]) conducted immediately after the gastrectomy.", + "On admission, brain CT revealed a 43 mm × 38 mm × 32 mm tumor in the left hemisphere of the cerebellum.", + "MRI revealed that the tumor was iso-to-hyperintense on T1-weighted image (T1WI) and hyperintense on T2WI.", + "The tumor demonstrated strong contrast enhancement after gadolinium injection.", + "Fluorodeoxyglucose positron emission-CT (18FDG-PET-CT) revealed FDG uptake of SUV max 7.17.", + "No other region with 18FDG uptake was detected.", + "The patient underwent standard suboccipital craniotomy without navigation or monitoring, performed in the prone position.", + "The cerebellar tumor was completely resected.", + "The consistency of the white–yellow tumor tissue was dense.", + "The tissue plane between tumor and normal brain was clearly identified.", + "Microscopic gross total resection was achieved.", + "His postoperative course was uneventful.", + "Postoperative MRI (within 24 h) and contrast MRI (within 72 h) revealed complete resection of the tumor.", + "Symptoms improved after surgery.", + "He had no deficit and was discharged to go home after 20 days from his operation.", + "Histopathological analysis showed a proliferation of spindle-to-polygonal-shaped tumor cells with enlarged irregular nuclei and eosinophilic cytoplasm arranged in sheet-like patterns.", + "The tumor was accompanied by chronic inflammatory infiltration.", + "The tumor showed hemangiopericytomas Staghorn-type branching vessels.", + "Employing Ki-67 stains, mitotic figures were frequently observed.", + "Tumor cells were positive for p53 and p16.", + "Tumor cells were focally positive for cytokeratin AE1/AE3 CAM5.3.", + "Tumor cells were focally positive for alpha-smooth muscle actin.", + "Tumor cells were focally positive for desmin.", + "Tumor cells were focally positive for muscle-specific actin (HHF35).", + "Tumor cells were negative for multiple other markers such as cytokeratin CK5/6, CK903, CK14, p40, EMA, GFAP, Oligo-2, IDH-1, ERG, STAT6, and GRIA2.", + "The automated count of MIB-1-labeling index was high and estimated at 37%.", + "We compared brain specimen from the specimen of the stomach after microscopic analysis.", + "Both specimens showed the same histological characteristic.", + "Pathological findings were compatible with that of metastatic tumors from gastric UPS.", + "The patient underwent repeat brain imaging after 1 and ½ months at follow-up.", + "No apparent brain tumor residual or recurrence was observed.", + "Only 2 weeks after that last visit, the patient started complaining of headache and nausea.", + "A repeat MRI was ordered, which revealed a 4-cm recurrent cerebellar tumor in the same region.", + "The 4-cm mass must have grown almost entirely within 2 weeks’ window.", + "Since 2 weeks prior, he had undergone a non-contrast CT with 5-mm slice thickness.", + "Systemic restaging was not performed because the pathological diagnosis was not clear.", + "Again, the patient was taken to surgery and the recurrent tumor mass was completely resected.", + "Histopathological findings were indistinguishable from the previous metastatic tumor.", + "The MIB-1 labeling index was 37%.", + "After the second operation, the patient received focused brain radiation therapy with added local irradiation (40Gy/20Fr).", + "The patient received three dimensional intensity-modulated radiation therapy (30 Gy/3 Fr) to the tumor cavity.", + "A second 9-mm metastatic brain tumor appeared in the temporal lobe.", + "At the time of radiation therapy to the two lesions of the CNS, further metastatic tumors were detected in the patient’s tonsils.", + "Systemic chemotherapy was initiated adriamycin (30 mg/m2) plus ifosfamide (2 g/m2) (AI) at an age-adjusted dose of 75%.", + "Chemotherapy was administered together with dexamethasone coverage.", + "The metastatic tonsilar tumor grew rapidly, indicating that chemotherapy was not effective.", + "Further local radiotherapy in this region also had no effect.", + "The patient was thus transferred to a palliative hospital where he expired 10 days later." + ], + "summary": "An 82-year-old man with a known gastric tumor, pathologically compatible with UPS, underwent partial gastrectomy at an outside facility. 3 months later, a 4-cm brain tumor was detected, which was completely resected. The patient was diagnosed with metastatic tumor from previously treated gastric UPS. Within 2 months of the initial resection, a large recurrent mass was detected in the same location, which was again removed. Although the patient underwent radiotherapy and chemotherapy for other metastatic tumors, he died 5 months after the second craniotomy.", + "summary_subclaims": [ + "The patient is an 82-year-old man.", + "The patient had a known gastric tumor.", + "The gastric tumor was pathologically compatible with UPS.", + "The patient underwent partial gastrectomy at an outside facility.", + "Three months later, a 4-cm brain tumor was detected.", + "The brain tumor was completely resected.", + "The patient was diagnosed with metastatic tumor from previously treated gastric UPS.", + "Within 2 months of the initial resection, a large recurrent mass was detected in the same location.", + "The recurrent mass was again removed.", + "The patient underwent radiotherapy and chemotherapy for other metastatic tumors.", + "The patient died 5 months after the second craniotomy." + ] + }, + { + "id": "multiclinsum_test_1596_en.txt", + "fulltext": "A 4-year-old boy was admitted because of persistent lower limb pain and claudication in the left lower limb over the past 9 mo.\nThe patient had mild persistent lower limb pain and claudication without any inducement. Claudication worsened in one day. The child had no fever, urinary frequency or urgency, numbness, fatigue, or lameness. For further assessment and treatment, he was admitted to our joint hand surgery department.\nThe child had no history past illness.\nThe child had no history of family illness, and his medical history was unremarkable.\nPressing pain and local swelling were present in the left shank. The results of sensation and strengthening test, and tendon reflex test were normal in both lower limbs. No pathological signs were observed upon physical examination.\nLaboratory examinations were normal.\nPreoperative imaging examinations, including X-ray photography, computed tomography, and magnetic resonance imaging, showed erosion-like changes with bone expansion of the left middle and lower fibular segment . No invasion of circumferential soft tissue or pathological fracture of the lesion site was observed. Initial pathological examination revealed fibular fibrous dysplasia . Postoperative photography showed that an allograft bone was implanted into the fibular medullary cavity . Recurrent fibular fibrous dysplasia was observed at the age of 6 years .", + "fulltext_subclaims": [ + "A 4-year-old boy was admitted because of persistent lower limb pain and claudication in the left lower limb over the past 9 mo.", + "The patient had mild persistent lower limb pain and claudication without any inducement.", + "Claudication worsened in one day.", + "The child had no fever, urinary frequency or urgency, numbness, fatigue, or lameness.", + "He was admitted to our joint hand surgery department.", + "The child had no history past illness.", + "The child had no history of family illness, and his medical history was unremarkable.", + "Pressing pain and local swelling were present in the left shank.", + "The results of sensation and strengthening test, and tendon reflex test were normal in both lower limbs.", + "No pathological signs were observed upon physical examination.", + "Laboratory examinations were normal.", + "Preoperative imaging examinations showed erosion-like changes with bone expansion of the left middle and lower fibular segment.", + "No invasion of circumferential soft tissue or pathological fracture of the lesion site was observed.", + "Initial pathological examination revealed fibular fibrous dysplasia.", + "Postoperative photography showed that an allograft bone was implanted into the fibular medullary cavity.", + "Recurrent fibular fibrous dysplasia was observed at the age of 6 years." + ], + "summary": "A 4-year-old boy was admitted for persistent pain in the left lower limb and abnormal gait over the previous 9 mo. He had no history of present or past illness. Preoperative imaging data showed erosion-like changes with bone expansion of the left middle and lower fibular segment. Tumor tissue in the fibular bone marrow cavity was removed by curettage, and rapid intraoperative pathological examination suggested fibular fibrous dysplasia. An allograft was implanted into the fibular medullary cavity. However, he was readmitted with clinical symptoms including persistent pain, abnormal gait, and local swelling at the age of 6 years. He was diagnosed with recurrent fibular fibrous dysplasia based on the second medical examination. He underwent fibular bone tumor radical resection and longus fibular allograft transplantation combined with fibular bone locking plate and screws. Good host bone to allogenic bone graft fusion was observed by the physician on postoperative regular follow-up.", + "summary_subclaims": [ + "A 4-year-old boy was admitted for persistent pain in the left lower limb and abnormal gait over the previous 9 mo.", + "He had no history of present or past illness.", + "Preoperative imaging data showed erosion-like changes with bone expansion of the left middle and lower fibular segment.", + "Tumor tissue in the fibular bone marrow cavity was removed by curettage.", + "Rapid intraoperative pathological examination suggested fibular fibrous dysplasia.", + "An allograft was implanted into the fibular medullary cavity.", + "He was readmitted with clinical symptoms including persistent pain, abnormal gait, and local swelling at the age of 6 years.", + "He was diagnosed with recurrent fibular fibrous dysplasia based on the second medical examination.", + "He underwent fibular bone tumor radical resection and longus fibular allograft transplantation combined with fibular bone locking plate and screws.", + "Good host bone to allogenic bone graft fusion was observed by the physician on postoperative regular follow-up." + ] + }, + { + "id": "multiclinsum_test_1934_en.txt", + "fulltext": "The patient, a 59-year-old female, presented with bilateral symmetrical low-key tinnitus and accompanying hearing loss three years ago. Over the past year, she experienced a progressively worsening blowing or running sound in her right ear, resembling a “murmur,” along with synchronous with her heartbeat rhythm. Concurrently, her original symptoms worsened, manifesting as slightly decreased visual acuity, insomnia, anxiety, depression, and suicidal ideation. She had previously been diagnosed with sudden deafness and received microcirculation treatment but did not experience any improvement.\nThe patient reported that the persistent tinnitus in his right ear was seriously affecting his normal life and urgently needed treatment. The patient had suffered from hypertension and hyperlipidemia in the past and was taking medication regularly to keep his blood pressure and blood lipids within normal limits, with no history of other illnesses, no history of allergies to medications or food, and no history of such hereditary diseases in his family. We assessed the patient's tinnitus, sleep and anxiety levels using the Tinnitus Handicap Inventory(THI), the Pittsburgh Sleep Quality Index (PSQI) and the Hamilton Depression Scale(HAMD), with the following results: THI: 56/100 points (Grade 3); PSQI: 14/21 points; and HAMD: 10 points, confirming moderate tinnitus handicap, sleep disorder, and mild anxiety state.\nAfter admission, we performed neurological examinations: (1) intracranial pressure was normal; (2) otoscopy: bilateral external auditory canals were patent, tympanic membranes were intact, grayish-white in color, and no congestion or fluid flatness was seen; the hearing loss was observed in both ears by pure tone audiometry, and tympanic ventricular conductance mapping showed a pattern of 3C; (3) A computed tomography (CT) scan of the right ear showed: normal right sigmoid sinus wall and stenosis at the junction of the right internal jugular vein(IJV) and the sigmoid sinus, as well as a high JB on the right accompanied with Jugular bulb wall dehiscence (JBWD) . Digital subtraction angiography (DSA) showed moderate-to-severe sigmoid sinus stenosis(SSS) at its junction with the IJV (stenosis of approximately 50%–70%) and a high JB , and distal venous sinus manometry was performed. Initially, we thought that the PT in the right ear might be due to the SSS increasing the blood flow velocity creating a vortex in the high JB, so that the PT sound entered the inner ear. Two other evidences supported our diagnosis: first, during DSA venography, the contrast catheter passed through the stenosis site, and when the pressure was measured at the distal end, it changed the direction of blood flow at the site, and the venous vortex flow was reduced, and the patient's PT disappeared; second, by the right side neck-pressure test, when the pressure was increased to a certain degree, the PT disappeared on the patient's right side after the venous reflux was blocked, and the left side hearing was not changed. However, the results of subsequent interventions confirmed more than just what was previously stated.", + "fulltext_subclaims": [ + "The patient is a 59-year-old female.", + "She presented with bilateral symmetrical low-key tinnitus and accompanying hearing loss three years ago.", + "Over the past year, she experienced a progressively worsening blowing or running sound in her right ear, resembling a 'murmur.'", + "The sound in her right ear was synchronous with her heartbeat rhythm.", + "Her original symptoms worsened, manifesting as slightly decreased visual acuity.", + "She had insomnia.", + "She had anxiety.", + "She had depression.", + "She had suicidal ideation.", + "She had previously been diagnosed with sudden deafness.", + "She received microcirculation treatment.", + "She did not experience any improvement.", + "The persistent tinnitus in his right ear was seriously affecting his normal life.", + "The patient had suffered from hypertension in the past.", + "The patient had suffered from hyperlipidemia in the past.", + "He was taking medication regularly to keep his blood pressure and blood lipids within normal limits.", + "He had no history of other illnesses.", + "He had no history of allergies to medications or food.", + "He had no history of such hereditary diseases in his family.", + "We assessed the patient's tinnitus, sleep and anxiety levels using the Tinnitus Handicap Inventory (THI), the Pittsburgh Sleep Quality Index (PSQI), and the Hamilton Depression Scale (HAMD).", + "The THI score was 56/100 points (Grade 3).", + "The PSQI score was 14/21 points.", + "The HAMD score was 10 points.", + "The results confirmed moderate tinnitus handicap.", + "The results confirmed sleep disorder.", + "The results confirmed mild anxiety state.", + "Intracranial pressure was normal.", + "Otoscopy showed bilateral external auditory canals were patent.", + "Tympanic membranes were intact, grayish-white in color, and no congestion or fluid flatness was seen.", + "Hearing loss was observed in both ears by pure tone audiometry.", + "Tympanic ventricular conductance mapping showed a pattern of 3C.", + "A CT scan of the right ear showed normal right sigmoid sinus wall.", + "A CT scan showed stenosis at the junction of the right internal jugular vein (IJV) and the sigmoid sinus.", + "A CT scan showed a high jugular bulb (JB) on the right.", + "A CT scan showed jugular bulb wall dehiscence (JBWD) on the right.", + "Digital subtraction angiography (DSA) showed moderate-to-severe sigmoid sinus stenosis (SSS) at its junction with the IJV (stenosis of approximately 50%–70%).", + "DSA showed a high JB.", + "Distal venous sinus manometry was performed.", + "Initially, we thought that the pulsatile tinnitus (PT) in the right ear might be due to the SSS increasing the blood flow velocity creating a vortex in the high JB, so that the PT sound entered the inner ear.", + "During DSA venography, the contrast catheter passed through the stenosis site.", + "When the pressure was measured at the distal end, it changed the direction of blood flow at the site.", + "The venous vortex flow was reduced.", + "The patient's PT disappeared.", + "By the right side neck-pressure test, when the pressure was increased to a certain degree, the PT disappeared on the patient's right side after the venous reflux was blocked.", + "The left side hearing was not changed.", + "The results of subsequent interventions confirmed more than just what was previously stated." + ], + "summary": "A 59-year-old woman presented with long-term tinnitus consistent with heart rhythm and hearing loss, accompanied by anxiety, insomnia, and depression. The results of brain MRV, CT, and DSA showed stenosis of the right sigmoid sinus and high jugular bulb (JB) with dehiscence of the JB wall. The patient saw a significant improvement in PT symptoms following sigmoid sinus stenting and spring coil embolization of the high JB, following the diagnosis of PT. The patient had no PT recurrence for the course of the 31-month follow-up period.", + "summary_subclaims": [ + "The patient is a 59-year-old woman.", + "The patient had long-term tinnitus consistent with heart rhythm.", + "The patient had hearing loss.", + "The patient had anxiety.", + "The patient had insomnia.", + "The patient had depression.", + "Brain MRV showed stenosis of the right sigmoid sinus.", + "Brain CT showed stenosis of the right sigmoid sinus.", + "Brain DSA showed stenosis of the right sigmoid sinus.", + "Brain MRV showed high jugular bulb with dehiscence of the jugular bulb wall.", + "Brain CT showed high jugular bulb with dehiscence of the jugular bulb wall.", + "Brain DSA showed high jugular bulb with dehiscence of the jugular bulb wall.", + "The patient had significant improvement in pulsatile tinnitus symptoms following sigmoid sinus stenting.", + "The patient had significant improvement in pulsatile tinnitus symptoms following spring coil embolization of the high jugular bulb.", + "The patient had no pulsatile tinnitus recurrence during the 31-month follow-up period." + ] + }, + { + "id": "multiclinsum_test_2000_en.txt", + "fulltext": "A 68-year-old Japanese male with sudden onset of abdominal pain was transferred to Nomura-Kaihin Hospital. He did not have any special past medical history and had never received colonoscopy. Contrast-enhanced computed tomography revealed a locally dilated sigmoid colon with fecaloma and perforation. Findings of feculent peritonitis (stage IV by Hinchey Classification) and free air in the peritoneal cavity were also detected, but no apparent tumor was pointed out. He was clinically diagnosed with perforation of the sigmoid colon, and an emergency operation was performed. During surgery, a diverticulum with wide frontage and rupture was found in the sigmoid colon, but no apparent tumor was observed. Fecaloma was present near the rupture site. The sigmoid colon measuring 16 cm in length including the perforated area was resected. The diverticulum with rupture was present at the contramesenteric side and was 55 × 35 mm in size .\nMicroscopically, bland spindle cells were present replacing the whole layer of the muscularis propria without forming an apparent mass at the true diverticulum . Necrosis was absent, and mitotic figure was difficult to detect at the lesion (0/50 high-power fields). The non-diverticulum-like portion at the mesenteric side showed normal structure of the colonic wall . Basically, the lamina propria, submucosa, and serosa even at the diverticulum-like portion did not show any specific changes , although the whole layer at the perforation site was necrotic. The perforation was observed near the boundary between the normal colonic wall and the lesional wall .\nImmunohistochemical examination revealed that the spindle cells were diffusely positive for KIT , DOG1 , and CD34 . Alpha-smooth muscle actin was partially positive, but S-100P was negative (data not shown). Since the muscularis propria layer was almost entirely replaced by the KIT-positive spindle cells , desmin was almost completely negative at the lesion. The Ki-67 labeling index was less than 1% (data not shown).\nMutational analysis of the c-kit gene at exons 9, 11, 13, and 17 where most mutations are detected in GISTs using macrodissected paraffin-embedded sections showed that the spindle cell lesion had a heterozygous deletion of 2 amino acids at codons 557 and 558 of exon 11 . There was no mutation at exons 9, 13, and 17. The surrounding normal mucosal tissue had a wild-type sequence for the c-kit gene . The PDGFRA mutation was detected neither in the lesion nor in the normal tissue (data not shown).\nThe patient had mild postoperative paralytic ileus and surgical wound infection but was discharged from the hospital approximately 3 weeks later. He received colonoscopy 6 months after the surgery without special abnormalities and has had no diagnostic imaging thereafter. He has been regularly followed once a month by his family doctor for hypertension and was free from apparent recurrence for 41 months after the surgery.", + "fulltext_subclaims": [ + "The patient was a 68-year-old Japanese male.", + "He had sudden onset of abdominal pain.", + "He was transferred to Nomura-Kaihin Hospital.", + "He did not have any special past medical history.", + "He had never received colonoscopy.", + "Contrast-enhanced computed tomography revealed a locally dilated sigmoid colon with fecaloma and perforation.", + "Findings of feculent peritonitis (stage IV by Hinchey Classification) were detected.", + "Free air in the peritoneal cavity was detected.", + "No apparent tumor was pointed out.", + "He was clinically diagnosed with perforation of the sigmoid colon.", + "An emergency operation was performed.", + "During surgery, a diverticulum with wide frontage and rupture was found in the sigmoid colon.", + "No apparent tumor was observed.", + "Fecaloma was present near the rupture site.", + "The sigmoid colon measuring 16 cm in length including the perforated area was resected.", + "The diverticulum with rupture was present at the contramesenteric side.", + "The diverticulum with rupture was 55 × 35 mm in size.", + "Microscopically, bland spindle cells were present replacing the whole layer of the muscularis propria without forming an apparent mass at the true diverticulum.", + "Necrosis was absent.", + "Mitotic figure was difficult to detect at the lesion (0/50 high-power fields).", + "The non-diverticulum-like portion at the mesenteric side showed normal structure of the colonic wall.", + "The lamina propria, submucosa, and serosa even at the diverticulum-like portion did not show any specific changes.", + "The whole layer at the perforation site was necrotic.", + "The perforation was observed near the boundary between the normal colonic wall and the lesional wall.", + "The spindle cells were diffusely positive for KIT.", + "The spindle cells were diffusely positive for DOG1.", + "The spindle cells were diffusely positive for CD34.", + "Alpha-smooth muscle actin was partially positive.", + "S-100P was negative.", + "The muscularis propria layer was almost entirely replaced by the KIT-positive spindle cells.", + "Desmin was almost completely negative at the lesion.", + "The Ki-67 labeling index was less than 1%.", + "The spindle cell lesion had a heterozygous deletion of 2 amino acids at codons 557 and 558 of exon 11.", + "There was no mutation at exons 9, 13, and 17.", + "The surrounding normal mucosal tissue had a wild-type sequence for the c-kit gene.", + "The PDGFRA mutation was detected neither in the lesion nor in the normal tissue.", + "The patient had mild postoperative paralytic ileus.", + "The patient had surgical wound infection.", + "He was discharged from the hospital approximately 3 weeks later.", + "He received colonoscopy 6 months after the surgery.", + "He had no special abnormalities at the colonoscopy.", + "He has had no diagnostic imaging thereafter.", + "He has been regularly followed once a month by his family doctor for hypertension.", + "He has been free from apparent recurrence for 41 months after the surgery." + ], + "summary": "A 68-year-old Japanese male with sudden onset of abdominal pain was clinically diagnosed with gastrointestinal perforation, and an emergency abdominal operation was performed. A diverticulum with rupture was found in the sigmoid colon, but no apparent tumor was observed. Histological examination revealed bland spindle cells flatly proliferating and diffusely replacing the muscularis propria at the diverticular structure. The spindle cells were positive for KIT, DOG1, and CD34. Mutational analysis of the c-kit gene revealed that the lesion had a heterozygous deletion of 2 amino acids at codons 557 and 558 of exon 11. The mutation was not observed in the normal mucosa of the surrounding tissue.", + "summary_subclaims": [ + "A 68-year-old Japanese male with sudden onset of abdominal pain was clinically diagnosed with gastrointestinal perforation.", + "An emergency abdominal operation was performed.", + "A diverticulum with rupture was found in the sigmoid colon.", + "No apparent tumor was observed.", + "Histological examination revealed bland spindle cells flatly proliferating and diffusely replacing the muscularis propria at the diverticular structure.", + "The spindle cells were positive for KIT.", + "The spindle cells were positive for DOG1.", + "The spindle cells were positive for CD34.", + "Mutational analysis of the c-kit gene revealed that the lesion had a heterozygous deletion of 2 amino acids at codons 557 and 558 of exon 11.", + "The mutation was not observed in the normal mucosa of the surrounding tissue." + ] + }, + { + "id": "multiclinsum_test_2162_en.txt", + "fulltext": "An 83-year-old Caucasian man, in otherwise good health, was referred to our hospital with intermittent anal bleeding and irregular bowel patterns. A colonoscopy revealed a 1cm solitary rectal polyp, which was completely removed by endoscopic resection .\nHistological examination showed a tubular adenoma with low-grade intraepithelial dysplasia and focal localization in the stroma by highly proliferative large lymphoid cells . The base of the adenoma was not involved.\nImmunohistochemical stains demonstrated that the lymphoid cells expressed CD20 (clone 2B11 + PD7/26, DAKO; Figure d and e) and B-cell lymphoma 2 (clone 2B11 + PD7/26, DAKO; figure not shown), but not CD3 (clone F7.2.38, DAKO), CD5 (clone 4C7, DAKO), CD10 (clone 56C6, DAKO), CD23 (clone DAK-CD23, DAKO), CD30 (clone Ber-H2, DAKO), CD138 (clone MI15, DAKO) and cyclin D1 (clone EP12, DAKO). Approximately 90% of the neoplastic cells reacted positively when stained with an antibody to Ki-67 (clone MIB1, DAKO; Figure f).\nFinally, molecular genetic analysis detecting the rearrangement of the FR2/LJH/VLJH region of the immunoglobulin heavy chain was performed and a monoclonal amplicon of approximately 260 base pairs (expected band between 240 and 280 base pairs) was detected, demonstrating malignancy and clonal association of the lymphoma infiltrates in the adenoma . Molecular analyses were carried out as previously described [,] and according to the manufacturer’s instructions. Commercial reagents by DAKO Cytomation, Milan, Italy and by Diachem S.r.l., Naples, Italy to perform immunohistochemical and a B clonality assay were used, respectively. All used products are compliant with the requirements of the in vitro diagnostic directive 98/79/EC.\nThe patient underwent full staging for lymphoma. Dawson’s criteria were used in the differential diagnosis between primary colorectal involvement and GI tract involvement secondary to systemic lymphoma . He had no fever, weight loss or night sweats. A physical examination revealed no alteration. There was no lymphadenopathy and hepatosplenomegaly. Blood-cell count, serum biochemistry and immunoglobulins were either within normal limits or negative. A bone marrow biopsy showed no evidence of lymphoma. His chest X-ray was unremarkable. Computed tomography (CT) of his total body revealed no evidence of extraintestinal involvement. A diagnosis of primary DLBCL was made. Ann Arbor stage 1A was established. Subsequently, he was referred to a hematologist for further management. Since the lymphoproliferative lesion was limited and there was no evidence of disseminated disease, and accounting for the advanced age of patient, it was considered inappropriate to perform surgical resection. He did not receive chemotherapy, but he was referred to follow-up with clinical examinations and CT scans at 6-monthly intervals only. He showed no clinical or radiologic recurrence at the time when we wrote this paper (1 year past).", + "fulltext_subclaims": [ + "An 83-year-old Caucasian man was referred to our hospital with intermittent anal bleeding and irregular bowel patterns.", + "A colonoscopy revealed a 1cm solitary rectal polyp.", + "The polyp was completely removed by endoscopic resection.", + "Histological examination showed a tubular adenoma with low-grade intraepithelial dysplasia.", + "Focal localization in the stroma by highly proliferative large lymphoid cells was observed.", + "The base of the adenoma was not involved.", + "Immunohistochemical stains demonstrated that the lymphoid cells expressed CD20 (clone 2B11 + PD7/26, DAKO).", + "The lymphoid cells expressed B-cell lymphoma 2 (clone 2B11 + PD7/26, DAKO).", + "The lymphoid cells did not express CD3 (clone F7.2.38, DAKO).", + "The lymphoid cells did not express CD5 (clone 4C7, DAKO).", + "The lymphoid cells did not express CD10 (clone 56C6, DAKO).", + "The lymphoid cells did not express CD23 (clone DAK-CD23, DAKO).", + "The lymphoid cells did not express CD30 (clone Ber-H2, DAKO).", + "The lymphoid cells did not express CD138 (clone MI15, DAKO).", + "The lymphoid cells did not express cyclin D1 (clone EP12, DAKO).", + "Approximately 90% of the neoplastic cells reacted positively when stained with an antibody to Ki-67 (clone MIB1, DAKO).", + "Molecular genetic analysis detected a monoclonal amplicon of approximately 260 base pairs.", + "The monoclonal amplicon demonstrated malignancy and clonal association of the lymphoma infiltrates in the adenoma.", + "The patient underwent full staging for lymphoma.", + "Dawson’s criteria were used in the differential diagnosis between primary colorectal involvement and GI tract involvement secondary to systemic lymphoma.", + "The patient had no fever, weight loss or night sweats.", + "A physical examination revealed no alteration.", + "There was no lymphadenopathy.", + "There was no hepatosplenomegaly.", + "Blood-cell count, serum biochemistry and immunoglobulins were either within normal limits or negative.", + "A bone marrow biopsy showed no evidence of lymphoma.", + "The chest X-ray was unremarkable.", + "Computed tomography of the total body revealed no evidence of extraintestinal involvement.", + "A diagnosis of primary DLBCL was made.", + "Ann Arbor stage 1A was established.", + "The patient was referred to a hematologist for further management.", + "It was considered inappropriate to perform surgical resection.", + "The patient did not receive chemotherapy.", + "The patient was referred to follow-up with clinical examinations and CT scans at 6-monthly intervals.", + "The patient showed no clinical or radiologic recurrence at the time when we wrote this paper." + ], + "summary": "An 83-year-old Caucasian man was referred to our hospital intermittent anal bleeding and irregular bowel. Colonoscopy revealed a 1cm solitary rectal polyp, which was completely removed by endoscopic resection. Histologic studies revealed low-grade intraepithelial dysplasia; the stroma of adenoma showed focal localization by highly proliferative lymphoid cells. Immunohistochemical analyses demonstrated that lymphoid cells were positive for CD20 and bcl2, whereas they were negative for CD3, CD5, CD10, CD23, CD30, CD138 and cyclin D1. Approximately 90% of the neoplastic cells reacted positively when stained with an antibody to Ki-67. Molecular studies showed the presence of a monoclonal immunoglobulin heavy chain gene rearrangement.To determine primary or secondary lymphoma localization, Dawson's criteria were applied to the case. A diagnosis of primary diffuse large B- lymphoma Ann Arbor stage 1A was established. Subsequently, the patient was referred to oncology to establish the stage and to select appropriate treatment.", + "summary_subclaims": [ + "The patient is an 83-year-old Caucasian man.", + "The patient was referred to the hospital for intermittent anal bleeding and irregular bowel.", + "Colonoscopy revealed a 1cm solitary rectal polyp.", + "The rectal polyp was completely removed by endoscopic resection.", + "Histologic studies revealed low-grade intraepithelial dysplasia.", + "The stroma of the adenoma showed focal localization by highly proliferative lymphoid cells.", + "Immunohistochemical analyses demonstrated that lymphoid cells were positive for CD20.", + "Immunohistochemical analyses demonstrated that lymphoid cells were positive for bcl2.", + "Immunohistochemical analyses demonstrated that lymphoid cells were negative for CD3.", + "Immunohistochemical analyses demonstrated that lymphoid cells were negative for CD5.", + "Immunohistochemical analyses demonstrated that lymphoid cells were negative for CD10.", + "Immunohistochemical analyses demonstrated that lymphoid cells were negative for CD23.", + "Immunohistochemical analyses demonstrated that lymphoid cells were negative for CD30.", + "Immunohistochemical analyses demonstrated that lymphoid cells were negative for CD138.", + "Immunohistochemical analyses demonstrated that lymphoid cells were negative for cyclin D1.", + "Approximately 90% of the neoplastic cells reacted positively when stained with an antibody to Ki-67.", + "Molecular studies showed the presence of a monoclonal immunoglobulin heavy chain gene rearrangement.", + "Dawson's criteria were applied to determine primary or secondary lymphoma localization.", + "A diagnosis of primary diffuse large B-cell lymphoma Ann Arbor stage 1A was established.", + "The patient was referred to oncology to establish the stage and to select appropriate treatment." + ] + }, + { + "id": "multiclinsum_test_603_en.txt", + "fulltext": "Patient 01B (G1 P1), the older brother of patient 01A, was 18 years old at the time of examination. He was of normal height and weight when compared to his peers. He had mild dysmorphic features including a depressed nasal bridge and midface hypoplasia. He had no history of respiratory infections or other major medical treatments and no history of seizures or epilepsy. He has not been hospitalized, and is otherwise healthy apart from an occasional cold. A previous computed tomography (CT) scan showed no obvious abnormalities. He learnt to walk at 20 months and currently walked and ran slightly unsteadily. He liked to walk on his toes, but could not jump with both feet off the floor. He had no language, but could passively understand simple phrases as spoken by his mother. He was able to eat by himself, and stayed in his room alone at all times other than meal times. He liked to look at cars on the street and was very excited by wheels. When happy, he put his hands to his mouth and laughed loudly. He flapped his hands a lot and did not engage in interaction with others, but laughed often. Although this patient was 18 years at the time of examination, his cognitive, language and motor skills were in the range of 6 to 15 months as measured by Bayley Scales of Infant Development-3 . His ADOS score of 17 was well above the cutoff for autistic disorder .", + "fulltext_subclaims": [ + "Patient 01B was 18 years old at the time of examination.", + "He was of normal height and weight when compared to his peers.", + "He had mild dysmorphic features including a depressed nasal bridge and midface hypoplasia.", + "He had no history of respiratory infections or other major medical treatments.", + "He has not been hospitalized.", + "A previous computed tomography (CT) scan showed no obvious abnormalities.", + "He learnt to walk at 20 months.", + "He walked and ran slightly unsteadily.", + "He liked to walk on his toes.", + "He could not jump with both feet off the floor.", + "He had no language.", + "He could passively understand simple phrases as spoken by his mother.", + "He stayed in his room alone at all times other than meal times.", + "He liked to look at cars on the street.", + "When happy, he put his hands to his mouth and laughed loudly.", + "He flapped his hands a lot.", + "He did not engage in interaction with others.", + "His cognitive, language and motor skills were in the range of 6 to 15 months as measured by Bayley Scales of Infant Development-3.", + "His ADOS score of 17 was well above the cutoff for autistic disorder." + ], + "summary": "Here, we identified a Chinese family with two brothers both inheriting a 2.2 Mb MECP2-containing duplication (151,369,305 - 153,589,577) from their mother. In addition, both brothers also had a 213.7 kb duplication on Chromosome 2, inherited from their father. The older brother also carried a 48.4 kb duplication on Chromosome 2 inherited from the mother, and a 8.2 kb deletion at 11q13.5 inherited from the father. Based on the published literature, MECP2 is the most autism-associated gene among the identified CNVs. Consistently, the boys displayed clinical features in common with other patients carrying MECP2 duplications, including intellectual disability, autism, lack of speech, slight hypotonia and unsteadiness of movement. They also had slight dysmorphic features including a depressed nose bridge, large ears and midface hypoplasia. Interestingly, they did not exhibit other clinical features commonly observed in American-European patients with MECP2 duplication, including recurrent respiratory infections and epilepsy.", + "summary_subclaims": [ + "A Chinese family with two brothers both inherited a 2.2 Mb MECP2-containing duplication from their mother.", + "Both brothers also had a 213.7 kb duplication on Chromosome 2, inherited from their father.", + "The older brother also carried a 48.4 kb duplication on Chromosome 2 inherited from the mother.", + "The older brother had an 8.2 kb deletion at 11q13.5 inherited from the father.", + "MECP2 is the most autism-associated gene among the identified CNVs.", + "The boys displayed clinical features in common with other patients carrying MECP2 duplications.", + "The boys had intellectual disability.", + "The boys had autism.", + "The boys had lack of speech.", + "The boys had slight hypotonia.", + "The boys had unsteadiness of movement.", + "The boys had slight dysmorphic features including a depressed nose bridge, large ears and midface hypoplasia.", + "They did not exhibit other clinical features commonly observed in American-European patients with MECP2 duplication, including recurrent respiratory infections and epilepsy." + ] + }, + { + "id": "multiclinsum_test_3093_en.txt", + "fulltext": "A 35-year-old male patient was brought to the emergency department after sustaining a high velocity motor vehicle accident. He was the driver of the car and was not wearing a seat belt. He presented with polytraumatism, severe head injury, right upper limb and left lower limb trauma. His Glasgow Coma Scale (GCS) score was 11/15 and he was agitated and uncooperative. He was intubated and sedated and transferred to the intensive care unit. His vital signs were stable and his laboratory tests were normal. His initial clinical examination revealed a dislocated right wrist and an open dislocation of the metatarsophalangeal (MTP) joint of the left hallux. There was no neurovascular compromise of the right upper limb or the left lower limb. The rest of the physical examination was unremarkable.\n\nThe initial radiological examination showed a pure medial and volar radiocarpal dislocation of the right wrist, with no associated fractures of the distal radius, ulna, or carpal bones (Moneim type II and Dumontier Type I). The radiological findings also showed a short ulnar head with radial-sided deformity, radioulnar convergence, erosive scalloping of distal radius, subchondral sclerosis of ulnar head, medial rotation of the scaphoid with the scaphoid tubercle located medially, extensively arched carpus, scapholunate diastasis, DRUJ diastasis, an increased scapholunate and scaphocapitate angles, a dorsal intercalated segment instability (DISI), and a trapezoid that articulated medially with the left aspect of scaphoid tubercle rather than its distal aspect. The elbow and forearm radiographs were normal. The contralateral wrist radiographs were normal.\n\nThe initial management consisted of closed reduction and radio-metacarpal external fixation of the right wrist. The reduction was achieved by applying traction and pressure on the carpus in a dorsal and lateral direction, while maintaining the wrist in flexion and ulnar deviation. The stability of the reduction was assessed by passive and active movements of the wrist and the fingers. The external fixator was locked in a neutral position of the wrist. The reduction and fixation were confirmed by postoperative radiographs. The patient was also treated for the left hallux open dislocation, which required surgical exploration, debridement, and serum rinsing, followed by reduction. The patient received prophylactic antibiotics and tetanus immunization.\n\nThe patient was kept under medically induced general anesthesia in the intensive care unit for 10 days, due to his severe head injury. He underwent a computed tomography (CT) scan of the brain, which revealed a non-operative extra dural hematoma and meningeal hemorrhage. He was gradually weaned off sedation and extubated, and his neurological status improved. He was then transferred to the orthopedic ward, where he received physiotherapy and occupational therapy. After the patient's awakening, he reported no previous injury or trauma of the right wrist, and no previous episodes of wrist instability or dislocation. He also reported suffering from mild mechanical wrist pain after major efforts, with a slight limitation of the supination movement. He denied any history of congenital anomalies, rheumatoid arthritis, or gout. He had no family history of wrist disorders.\n\nThe follow-up radiological examination showed a satisfactory reduction and alignment of the radiocarpal joint, but a persistent ulnar impingement syndrome, an extensively arched carpus and a medially rotated scaphoid. The patient was informed about the nature and the severity of his injury and the possible treatment options. He consented to undergo a subsequent surgery to address the ulnar impingement syndrome, the arched carpus and the scaphoid rotation. The patient was scheduled for a definitive surgical treatment of his right wrist, which was performed 4 weeks after the initial injury. The surgery consisted of three steps: Sauvé-Kapandgi procedure, ulnolunate and ulnotriquetral ligamentoplasty using palmaris longus tendon, and scapholunate fusion. The surgery was performed under general anesthesia and tourniquet control, using a dorsal approach. The external fixator was removed, and the radiocarpal joint was exposed. The joint was found to be unstable and incongruent. The scapholunate ligament was found to be elongated but not ruptured with no macroscopic evidence of injury. The Sauvé-Kapandgi procedure was performed by resecting the distal 1 cm of the ulna, creating a pseudarthrosis between the ulnar stump and the ulnar head, and stabilizing the DRUJ with two 2.4 mm cortical screws. The ulnolunate and ulnotriquetral ligamentoplasty was performed by harvesting the palmaris longus tendon, passing it through drill holes in the ulnar stump, the lunate, and the triquetrum, and suturing it in a tensioned fashion using two suture anchors. The scapholunate fusion was performed by debriding the scapholunate joint, inserting a cancellous bone graft harvested from the distal radius, and fixing the scaphoid and the lunate with two headless compression screws. The wound was closed in layers and a long arm splint was applied. The surgery was uneventful and the intraoperative radiographs confirmed the adequacy of the procedures.\n\nThe patient was followed up regularly in the outpatient clinic. The long arm splint was replaced by a short arm splint after 8 weeks, The patient was allowed to start active and passive range of motion exercises of the wrist and the forearm and the patient was encouraged to resume his daily activities. The radiographs showed proper bone healing and no signs of infection, nonunion, or hardware failure. The patient reported significant improvement in his pain and function of the right wrist. He was able to perform most of his personal and professional tasks without difficulty. He was satisfied with the cosmetic appearance of his wrist and had no complaints of ulnar impingement or instability. The patient was evaluated at 6 months and 12 months after the surgery, with a Patient-Rated Wrist Evaluation (PRWE) score of 15, a Disabilities of the Arm, Shoulder and Hand (DASH) score of 18, and a Visual Analog Scale (VAS) of 2 for pain. The radiographs showed no changes in the bone alignment or the hardware position.", + "fulltext_subclaims": [ + "The patient was a 35-year-old male.", + "He was brought to the emergency department after a high velocity motor vehicle accident.", + "He was the driver of the car and was not wearing a seat belt.", + "He presented with polytraumatism.", + "He had a severe head injury.", + "He had right upper limb and left lower limb trauma.", + "His Glasgow Coma Scale (GCS) score was 11/15.", + "He was agitated and uncooperative.", + "He was intubated and sedated.", + "He was transferred to the intensive care unit.", + "His vital signs were stable.", + "His laboratory tests were normal.", + "The initial clinical examination revealed a dislocated right wrist.", + "The initial clinical examination revealed an open dislocation of the metatarsophalangeal (MTP) joint of the left hallux.", + "There was no neurovascular compromise of the right upper limb.", + "There was no neurovascular compromise of the left lower limb.", + "The rest of the physical examination was unremarkable.", + "The initial radiological examination showed a pure medial and volar radiocarpal dislocation of the right wrist.", + "There were no associated fractures of the distal radius, ulna, or carpal bones.", + "The radiological findings showed a short ulnar head with radial-sided deformity.", + "The radiological findings showed radioulnar convergence.", + "The radiological findings showed erosive scalloping of distal radius.", + "The radiological findings showed subchondral sclerosis of ulnar head.", + "The radiological findings showed medial rotation of the scaphoid with the scaphoid tubercle located medially.", + "The radiological findings showed an extensively arched carpus.", + "The radiological findings showed scapholunate diastasis.", + "The radiological findings showed DRUJ diastasis.", + "The radiological findings showed an increased scapholunate and scaphocapitate angles.", + "The radiological findings showed a dorsal intercalated segment instability (DISI).", + "The radiological findings showed a trapezoid that articulated medially with the left aspect of scaphoid tubercle rather than its distal aspect.", + "The elbow and forearm radiographs were normal.", + "The contralateral wrist radiographs were normal.", + "The initial management consisted of closed reduction and radio-metacarpal external fixation of the right wrist.", + "The reduction was achieved by applying traction and pressure on the carpus in a dorsal and lateral direction.", + "The reduction was achieved while maintaining the wrist in flexion and ulnar deviation.", + "The stability of the reduction was assessed by passive and active movements of the wrist and the fingers.", + "The external fixator was locked in a neutral position of the wrist.", + "The reduction and fixation were confirmed by postoperative radiographs.", + "The patient was treated for the left hallux open dislocation.", + "The treatment for the left hallux open dislocation required surgical exploration.", + "The treatment for the left hallux open dislocation required debridement.", + "The treatment for the left hallux open dislocation required serum rinsing.", + "The treatment for the left hallux open dislocation required reduction.", + "The patient received prophylactic antibiotics.", + "The patient received tetanus immunization.", + "The patient was kept under medically induced general anesthesia in the intensive care unit for 10 days.", + "The patient underwent a computed tomography (CT) scan of the brain.", + "The CT scan revealed a non-operative extra dural hematoma.", + "The CT scan revealed meningeal hemorrhage.", + "The patient was gradually weaned off sedation.", + "The patient was extubated.", + "The patient's neurological status improved.", + "The patient was transferred to the orthopedic ward.", + "The patient received physiotherapy.", + "The patient received occupational therapy.", + "After the patient's awakening, he reported no previous injury or trauma of the right wrist.", + "After the patient's awakening, he reported no previous episodes of wrist instability or dislocation.", + "After the patient's awakening, he reported suffering from mild mechanical wrist pain after major efforts.", + "After the patient's awakening, he reported a slight limitation of the supination movement.", + "The patient denied any history of congenital anomalies.", + "The patient denied any history of rheumatoid arthritis.", + "The patient denied any history of gout.", + "The patient had no family history of wrist disorders.", + "The follow-up radiological examination showed a satisfactory reduction and alignment of the radiocarpal joint.", + "The follow-up radiological examination showed a persistent ulnar impingement syndrome.", + "The follow-up radiological examination showed an extensively arched carpus.", + "The follow-up radiological examination showed a medially rotated scaphoid.", + "The patient was informed about the nature and the severity of his injury.", + "The patient was informed about the possible treatment options.", + "The patient consented to undergo a subsequent surgery.", + "The patient was scheduled for a definitive surgical treatment of his right wrist.", + "The surgery was performed 4 weeks after the initial injury.", + "The surgery consisted of three steps.", + "The first step was a Sauvé-Kapandgi procedure.", + "The second step was ulnolunate and ulnotriquetral ligamentoplasty using palmaris longus tendon.", + "The third step was scapholunate fusion.", + "The surgery was performed under general anesthesia.", + "The surgery was performed using tourniquet control.", + "The surgery used a dorsal approach.", + "The external fixator was removed.", + "The radiocarpal joint was exposed.", + "The joint was found to be unstable and incongruent.", + "The scapholunate ligament was found to be elongated.", + "The scapholunate ligament was found to be not ruptured.", + "There was no macroscopic evidence of injury to the scapholunate ligament.", + "The Sauvé-Kapandgi procedure was performed by resecting the distal 1 cm of the ulna.", + "The Sauvé-Kapandgi procedure created a pseudarthrosis between the ulnar stump and the ulnar head.", + "The Sauvé-Kapandgi procedure stabilized the DRUJ with two 2.4 mm cortical screws.", + "The ulnolunate and ulnotriquetral ligamentoplasty was performed by harvesting the palmaris longus tendon.", + "The ulnolunate and ulnotriquetral ligamentoplasty passed the tendon through drill holes in the ulnar stump, the lunate, and the triquetrum.", + "The ulnolunate and ulnotriquetral ligamentoplasty sutured the tendon in a tensioned fashion using two suture anchors.", + "The scapholunate fusion was performed by debriding the scapholunate joint.", + "The scapholunate fusion inserted a cancellous bone graft harvested from the distal radius.", + "The scapholunate fusion fixed the scaphoid and the lunate with two headless compression screws.", + "The wound was closed in layers.", + "A long arm splint was applied.", + "The surgery was uneventful.", + "The intraoperative radiographs confirmed the adequacy of the procedures.", + "The patient was followed up regularly in the outpatient clinic.", + "The long arm splint was replaced by a short arm splint after 8 weeks.", + "The patient was allowed to start active and passive range of motion exercises of the wrist and the forearm.", + "The patient was encouraged to resume his daily activities.", + "The radiographs showed proper bone healing.", + "The radiographs showed no signs of infection.", + "The radiographs showed no signs of nonunion.", + "The radiographs showed no signs of hardware failure.", + "The patient reported significant improvement in his pain.", + "The patient reported significant improvement in the function of the right wrist.", + "The patient was able to perform most of his personal and professional tasks without difficulty.", + "The patient was satisfied with the cosmetic appearance of his wrist.", + "The patient had no complaints of ulnar impingement.", + "The patient had no complaints of instability.", + "The patient was evaluated at 6 months and 12 months after the surgery.", + "The patient had a Patient-Rated Wrist Evaluation (PRWE) score of 15.", + "The patient had a Disabilities of the Arm, Shoulder and Hand (DASH) score of 18.", + "The patient had a Visual Analog Scale (VAS) of 2 for pain." + ], + "summary": "The patient had a pre-existing short ulnar head with radial-sided deformity, radioulnar convergence, negative ulnar variance, erosive scalloping of the distal radius, subchondral sclerosis of the ulnar head, scapholunate diastasis, and distal radioulnar joint (DRUJ) diastasis. Following a high-velocity motor vehicle accident, the initial treatment involved closed reduction and radio-metacarpal external fixation. Additionally, surgical intervention was required for an open dislocation of the metatarsophalangeal (MTP) joint of the left hallux.", + "summary_subclaims": [ + "The patient had a pre-existing short ulnar head.", + "The patient had radial-sided deformity.", + "The patient had radioulnar convergence.", + "The patient had negative ulnar variance.", + "The patient had erosive scalloping of the distal radius.", + "The patient had subchondral sclerosis of the ulnar head.", + "The patient had scapholunate diastasis.", + "The patient had distal radioulnar joint (DRUJ) diastasis.", + "The initial treatment involved closed reduction.", + "The initial treatment involved radio-metacarpal external fixation.", + "Surgical intervention was required for an open dislocation of the metatarsophalangeal (MTP) joint of the left hallux." + ] + }, + { + "id": "multiclinsum_test_2337_en.txt", + "fulltext": "A19-year-old male with sudden chest discomfort was admitted to the hospital. He had no past medical history. He did not have bloody stools or symptoms of upper respiratory infection before the onset of chest discomfort. He complained of general fatigue and shortness of breath upon exertion. Physiological examination findings were not noteworthy; no skin lesions were noted, blood pressure was 104/54 mmHg, heart rate was 67 beats per minute, and oxygen saturation was 99% on room air. Careful follow-up was performed without inotropic therapy. The initial electrocardiogram (ECG) showed sinus rhythm with a right bundle branch block, ST segment elevation in II, III, aVF, V4, V5, and V6, and abnormal Q waves in the same leads . Peripheral blood tests revealed remarkably elevated troponin T and creatinine kinase levels . Echocardiography demonstrated moderate left ventricular hypertrophy accompanied by oedema and left ventricular ejection fraction (LVEF) of 42% with patchy areas of reduced wall motion. Coronary angiography did not reveal significant stenosis (see , ). Patchy areas of reduced wall motion were demonstrated by LV angiography (see , and ). Endomyocardial biopsy from the right ventricular septum showed no pathological findings that were consistent with myocarditis . Subsequent tests reported high levels of soluble interleukin-2 receptor and lysozyme . Cardiac magnetic resonance (CMR) with contrast revealed myocardial late gadolinium enhancement (LGE) predominantly on the epicardial side of the posterolateral wall . Fluorine-18-fluorodeoxyglucose (18F-FDG) positron emission tomography (PET) revealed fluorodeoxyglucose accumulation in the same regions as LGE detected with CMR and in the transverse colon and sigmoid colon ( and ), but there was no abnormal accumulation in the respiratory tracts. Faecal occult blood was positive, so colonoscopy was performed. Inflammatory changes were observed in the transverse colon . Epithelioid granulomas were found in a biopsy specimen from the transverse colon .\nBased on these findings, we made a clinical diagnosis of active CS. We administered oral prednisolone (30 mg/day). The dose of prednisolone was decreased by 5 mg each month. At 6-month follow-up, LVEF (57%), and follow-up colonoscopy revealed significant resolution of inflammation. When PET was performed 1 year later, there was still strong accumulation of FDG in the heart ( and ). After the examination, the patient experienced sudden runs of sustained ventricular tachycardia with loss of consciousness at rest. He was admitted to our hospital again. We performed implantable cardioverter-defibrillator placement. At 4 months after the addition of methotrexate (8 mg/week), there was markedly less cardiac accumulation of FDG ( and ). Eight months have passed since the addition of methotrexate, there is no episode of heart failure admission nor shock therapy.", + "fulltext_subclaims": [ + "The patient is a 19-year-old male.", + "He had sudden chest discomfort.", + "He was admitted to the hospital.", + "He had no past medical history.", + "He did not have bloody stools before the onset of chest discomfort.", + "He did not have symptoms of upper respiratory infection before the onset of chest discomfort.", + "He complained of general fatigue.", + "He complained of shortness of breath upon exertion.", + "Physiological examination findings were not noteworthy.", + "No skin lesions were noted.", + "Blood pressure was 104/54 mmHg.", + "Heart rate was 67 beats per minute.", + "Oxygen saturation was 99% on room air.", + "Careful follow-up was performed without inotropic therapy.", + "The initial ECG showed sinus rhythm with a right bundle branch block.", + "The initial ECG showed ST segment elevation in II, III, aVF, V4, V5, and V6.", + "The initial ECG showed abnormal Q waves in the same leads.", + "Peripheral blood tests revealed remarkably elevated troponin T levels.", + "Peripheral blood tests revealed remarkably elevated creatinine kinase levels.", + "Echocardiography demonstrated moderate left ventricular hypertrophy.", + "Echocardiography demonstrated oedema.", + "Echocardiography showed left ventricular ejection fraction of 42%.", + "Echocardiography showed patchy areas of reduced wall motion.", + "Coronary angiography did not reveal significant stenosis.", + "Patchy areas of reduced wall motion were demonstrated by LV angiography.", + "Endomyocardial biopsy from the right ventricular septum showed no pathological findings consistent with myocarditis.", + "Subsequent tests reported high levels of soluble interleukin-2 receptor.", + "Subsequent tests reported high levels of lysozyme.", + "CMR with contrast revealed myocardial late gadolinium enhancement predominantly on the epicardial side of the posterolateral wall.", + "18F-FDG PET revealed fluorodeoxyglucose accumulation in the same regions as LGE detected with CMR.", + "18F-FDG PET revealed fluorodeoxyglucose accumulation in the transverse colon.", + "18F-FDG PET revealed fluorodeoxyglucose accumulation in the sigmoid colon.", + "There was no abnormal accumulation in the respiratory tracts.", + "Faecal occult blood was positive.", + "Colonoscopy was performed.", + "Inflammatory changes were observed in the transverse colon.", + "Epithelioid granulomas were found in a biopsy specimen from the transverse colon.", + "A clinical diagnosis of active CS was made.", + "Oral prednisolone (30 mg/day) was administered.", + "The dose of prednisolone was decreased by 5 mg each month.", + "At 6-month follow-up, LVEF was 57%.", + "Follow-up colonoscopy revealed significant resolution of inflammation.", + "PET performed 1 year later showed strong accumulation of FDG in the heart.", + "The patient experienced sudden runs of sustained ventricular tachycardia with loss of consciousness at rest.", + "He was admitted to the hospital again.", + "Implantable cardioverter-defibrillator placement was performed.", + "At 4 months after the addition of methotrexate (8 mg/week), there was markedly less cardiac accumulation of FDG.", + "Eight months have passed since the addition of methotrexate.", + "There is no episode of heart failure admission.", + "There is no episode of shock therapy." + ], + "summary": "A 19-year-old male was admitted for chest symptoms accompanied by remarkably elevated troponin T and creatinine kinase levels. Electrocardiogram (ECG) showed sinus rhythm with a right bundle branch block, broad ST segment elevation, and abnormal Q waves. Endoscopic biopsy revealed granuloma formation in the transverse colon. Based on multimodal imaging, we made a clinical diagnosis of extrapulmonary sarcoidosis involving only the heart and guts. One year of immunosuppressive therapy with prednisolone resolved the inflammation in the guts but not in the heart. He experienced runs of sustained ventricular tachycardia with loss of consciousness and was admitted to our hospital again. The addition of methotrexate markedly reduced cardiac accumulation of fluorodeoxyglucose. No life-threatening ventricular arrhythmias have been recorded afterwards.", + "summary_subclaims": [ + "The patient is a 19-year-old male.", + "The patient was admitted for chest symptoms.", + "Troponin T was remarkably elevated.", + "Creatinine kinase levels were remarkably elevated.", + "Electrocardiogram showed sinus rhythm.", + "Electrocardiogram showed a right bundle branch block.", + "Electrocardiogram showed broad ST segment elevation.", + "Electrocardiogram showed abnormal Q waves.", + "Endoscopic biopsy revealed granuloma formation in the transverse colon.", + "The clinical diagnosis was extrapulmonary sarcoidosis involving only the heart and guts.", + "One year of immunosuppressive therapy with prednisolone resolved the inflammation in the guts.", + "One year of immunosuppressive therapy with prednisolone did not resolve the inflammation in the heart.", + "The patient experienced runs of sustained ventricular tachycardia.", + "The patient had loss of consciousness.", + "The addition of methotrexate markedly reduced cardiac accumulation of fluorodeoxyglucose.", + "No life-threatening ventricular arrhythmias have been recorded afterwards." + ] + } +] \ No newline at end of file